Referral For Multidisciplinary Team Evaluation (7-12) Form Page 3
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4Referral for Multidisciplinary Team Evaluation (7-12)
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Were there any special problems in the growth/development of your child during the first few years?
Yes
No
If yes, describe ____________________________________________________
__________________________________________________________________________________________
Please list any serious illnesses, injuries, or surgeries your child has had. Also, note the approximate date (or
child's age at the time) ______________________________________________________________________
Has your child ever been hospitalized? Yes
No
If yes, length of stay: __________________
Reason: _____________________________
Has your child ever experienced seizures? Yes ______ No ____
If yes, describe______________________
__________________________________________________________________________________________
C.
Present Health
Child’s Physician _________________________________________________________________________
Does your child presently have any medical problems (illnesses, etc.)? Yes
No ____
If yes, describe _________________________________________________________________
____________________________________________________________________________________
Diagnosed when?_____________________________________________________________________
Does your child take any medication on a regular basis? Yes
No ______
If yes, Medication Name
Purpose
Dosage
Start Date
Side Effect
________________________
________________________
________________________
________________________
Place ** next to medications listed above which are taken at school.
Medications taken in the past, but not presently ___________________________________________________
__________________________________________________________________________________________
Has anyone suggested to you that your child may benefit from medication? Yes ___ No ___
If yes, describe _____________________________________________________________________
Does your child have any vision problems? Yes
No _____
Date of last exam
Physician ________________ Results ________________________
Does your child have any hearing problems? Yes
No _____
Date of last exam
Physician/audiologist ___________ Results ____________________
Has the child ever had tubes in his/her ears? Yes
No
If yes, when?_________________
Does your child have any difficulties with:
Large motor skills (i.e. walking, riding a bike, etc.)?
Yes ____ No ___ Describe: ____________
____________________________________________________________________________________
Small motor skills (i.e. using hands, drawing/cutting/writing, etc.)? Yes ____ No ___ Describe: ______
____________________________________________________________________________________
Does your child have difficulties with any of the following? If yes, describe on the lines below:
Grinds teeth
Yes ___ No ___
Mouths clothes/inedible objects
Yes ___ No ___
Avoids eye contact
Yes ___ No ___
Negative reaction to being touched Yes___ No ___
Negative reaction to sounds Yes ___ No ___
Unusual reaction to pain
Yes ___ No ___
Seeks or avoids odors
Yes ___ No ___
Extremely limited food preferences Yes ___ No ___
Describe any Yes answer above: _______________________________________________________________
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