Person Completing Form:Relationships to childDateChild’s Name:Date of BirthAgeGenderMaleFemaleReferring MDPrimary MD (if different)How did you hear about our clinic? (Doctor, other patient, advertising…)Thank you for taking the time to fill out this form as completely and honestly as possible. Your input plays a very important role in the evaluation process. All the information on this form is confidential and will not be released without your permission. Social/Language/Educational InformationMother’s Name:AgeOccupation:Father’s Name:AgeOccupation:Is this child:Your Biological ChildStep ChildAdopted ChildFoster ChildIf not your biological child, at what age did he/she come into your home?Persons living in the home:Language spoken in the home:Languages spoken by your child:Languages spoken by your child:YesNoIf yes, please describe:Name of school or daycareHours a week?Specialized Program?YesNoHealth / Medical HistoryPlease list any complications with pregnancy or birth:Please list all current and past medical diagnoses related to your child’s over-all developmentIs your child taking any medications?YesNoPlease list medication(s), dosage, and why used:Please list any Allergies and reactions your child has when exposed: (Medication, Food, Latex, Adhesives, etc.)If your child has no known allergies, check the box below.No Known AllergiesSubmit
