Please tell us about the medications and/or supplements that have been tried with your child in the past by completing the table below.
If you answer yes to each current medication, please provide the "Dose/Include Maximum Dose Tried", "Date/Length of Trial", and "RESULTS/Reason for stopping (side effects)". Otherwise, please leave these empty.
Please tell us about your child’s previous evaluations by completing the table below:
Please describe your child’s medical history:
Has your child ever had any problems in the following areas (please describe):
PLEASE TELL US ABOUT YOUR CHILD’S DEVELOPMENT
What age was your child when he/she:
TOILET TRAINING: Dry days
TOILET TRAINING: Dry nights
TOILET TRAINING: No accidents
Rode a tricycle:
Drank from a cup w/o spilling:
Used a spoon:
Talked (single word):
Talked in phrases:
Talked in sentences:
Echolalia (repeating words or sentences)
Undressed without help:
Dressed without help
Brushed hair without help
Bathed without help
Brushed teeth without help
Please tell us about your family’s history by checking all that apply below:
Please tell us about your child’s school history:
WE WOULD LIKE TO KNOW HOW YOU ARE DOING:
THANK YOU FOR COMPLETING THIS QUESTIONNAIRE. WE HOPE THAT THE INFORMATION YOU HAVE PROVIDED WILL HELP US TO BETTER UNDERSTAND YOUR CHILD AND PROVIDE YOUR FAMILY WITH THE BEST CARE.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.