Form 581-1378-E - Ei/ecse Health Screening Checklist- Oregon
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1
2EI/ECSE HEALTH SCREENING CHECKLIST
Dear Parent or Guardian:
The information on this questionnaire will help us to know whether your child's health is
affecting development and will help us plan for early intervention services.
(Provide details for any YES answers.)
Child's Name:
_______________________ DOB: _________ Contractor ____________
Date Completed: _____________________ Person Completing: ____________________
Primary Language: ___________________ Relationship to Child: ____________________
Reason for Referral to EI/ECSE: ________________________________________________
1a. Yes No Were there any complications during pregnancy, labor or delivery?
If yes, explain
__________________________________________________
1b. Yes No Did your child have any serious difficulties at birth?
If yes, explain
__________________________________________________
2a. Yes No Do you have any concerns about your child's nutrition or growth?
If yes, explain
__________________________________________________
2b. Yes No Is your child on a special diet?
If yes, explain
__________________________________________________
2c. Yes No Does your child have difficulties with feeding (such as choking, gagging,
coughing, vomiting, slow to complete a meal)?
If yes, explain
__________________________________________________
2d. Yes No Does your child require special feeding techniques (such as adapted utensils,
special positions)?
3.
Yes No Does your child have a history of neurologic problems (such as seizures?
epilepsy, muscle weakness, hydrocephalus or cerebral palsy)?
If yes, explain
__________________________________________________
4.
Yes No Does your child have an orthopedic problem (such as scoliosis, hand or foot
deformity, hip dislocation)?
If yes, explain
5.
Yes No Does your child have any birth defect or genetic problem (such as cleft
palate, heart defect or Down Syndrome)?
If yes, explain
__________________________________________________
6a. Yes No Does your child have a history of chronic illness (such as diabetes,
asthma or kidney problem)?
If yes, explain
__________________________________________________
6b. Yes No Has your child been hospitalized, had surgery or a serious injury?
If yes, explain
__________________________________________________
7a. Yes No Do you have any concerns about your child's hearing?
If yes, explain
__________________________________________________
7b
Yes No Has your child's hearing been tested?
If yes, please specify where, when and what were the results _____________
______________________________________________________________
Form 581-1378-E (2/09)
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Parent category: Medical