Health And Developmental History Initial Assessment Form Page 3
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4CURRENT HEALTH
Name of Physician: ___________________ Date of last visit: ______________ Reason: _________________
Name of Dentist: _____________________ Date of last visit: ______________ Reason: _________________
Professional hearing exam:
Yes
No
Date: _________________
Glasses/contacts:
Yes
No
Professional vision exam:
Yes
No
Date: _________________
Hearing aid:
Yes
No
Are your child’s immunizations up to date?
Yes
No
Does your child use any assistive devices/appliances? ______________________________________________
Does your child take any medication:
Yes
No
If yes, please provide list of current medications (including
over-the-counter medications such as multivitamins and herbal medications such as melatonin):
Name _____________________________ Dose __________________ Time Administered ______________
Name _____________________________ Dose __________________ Time Administered ______________
Name _____________________________ Dose __________________ Time Administered ______________
***If your child will require any medications or medical procedures at school,
medical records and doctors’ orders will be required***
Please list any other specialty physicians, treatment centers, special schools and/or social agencies who have
examined, cared for, or provided services to your child:
Name
Address
Phone
Reason
Date(s) Seen
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
NUTRITION/ACTIVITY
How many meals/snacks does your child eat per day? 1 2 3 4 5 6 7
Please check if your child regularly (every day) eats or drinks the following:
Meat
Milk
Fruits
Vegetables
Sports/activities your child is involved in: __________________________ How often? ___________________
Does your child have any swallowing or feeding problems?
Yes
No
If yes, please describe:
___________________________________________________________________________________
Do you have any concerns with your child’s current:
Diet
Weight
Activity level
If yes, please describe:
____________________________________________________________________________________
____________________________________________________________________________________
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