Referral For Initial Multidisciplinary Team Evaluation (50 Day Timeline) Form Page 3
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Referral for Multidisciplinary Team Evaluation
Page
The following is a list of infant and preschool behaviors. Please indicate the age at which your child first
demonstrated each behavior. If you are not certain of the age but have some idea, write the age followed by a
question mark. If you don't remember the age at which the behavior occurred, please write a question mark.
Behavior
Age
Behavior
Age
Sat alone
Put several words together
______
Crawled
Became toilet trained
______
Walked alone
Stayed dry at night
______
Spoke first word
______
Describe your child’s early language development: _______________________________________________
_________________________________________________________________________________________
Does your child have any speech problems? Yes____ No____ If yes, describe___________________________
__________________________________________________________________________________________
Did your child previously receive speech/language therapy? Yes ____ No ____
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______________________
__________________________________________________________________________________________
Present Health
Child’s Physician _________________________________________________________________________
Does your child presently have any medical problems (illnesses, etc.)? Yes
No ____
Medical Condition
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 _____
Glasses prescribed? 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: ______
____________________________________________________________________________________
Rev. 6/12
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