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Please List any Hospitalizations or Emergency Room Visits
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Year
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Reason for Hospitalization:
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Year
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Reason for Hospitalization:
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Year
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Reason for Hospitalization:
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Please list any medical specialist that your child has seen in the past or is presently seeing:
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Please indicate any testing your child has had (choose all that apply)
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Other testing not listed
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Sensory Issues (Please select all that apply):
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Educational
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Is this child in a self-contained special class?
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How many students in the class?
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How many teachers in the class?
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Special education teacher?
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Mainstream teacher?
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Does your child receive academic support?
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If yes, please describe the type of support & subjects:
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Does your child receive academic tutoring?
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If yes, please list subject(s):
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What are your child's best subject areas and average report card grade in these subject(s)?
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What are your child's worst subject areas and average report card grade in these subject(s)?
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Are you satisfied with your child's current educational program?
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If not, why?
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Has your child ever repeated a grade?
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Does your child have problems relating to or playing with other children?
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If yes, select all that apply:
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If other, please describe:
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What activities does your child enjoy?
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Please describe:
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Has your child's interest in participating in these activities declined recently?
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If yes, please explain:
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Sleep Habits
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What time does your child go to bed?
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What time does your child fall asleep?
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Select all that apply:
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If "Night Awakenings" selected, how often?
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Eating Habits
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Please select all that apply:
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Please explain:
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Does this child sit for meals?
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Schools Attended
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Early Intervention: 0 to 3
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County:
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Service Coordinator
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Please list services received:
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Preschool - Name of School
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What age?
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How many hours per day?
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How many days per week?
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Please list any services received
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Please describe any problems experienced in Preschool
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Kindergarten - Name of School
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What age?
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How many hours per day?
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How many days per week?
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Please describe any problems experienced in Kindergarten
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Elementary - Name of School
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Grades Attended (ex 1-5 or 2-6, etc)
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Please describe any problems in elementary school
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Please list any services or supports received
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Middle/Junior High School - Name of School
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Grades attended
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Please describe any problems
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Please list any services or support received
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High School - Name of School
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Grades Attended
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Please describe any problems
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Please any services or support received
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