Other children in the family:
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:
Has your child ever had any problems in the following areas (please describe):
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.
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