Family And Medical History Form Page 6

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ITEM
NO
YES
DESCRIPTION
EXPLANATION
1
Sleeping problems
2
Bed wetting
3
Drooling
4
Thumb sucking
5
Temper tantrums
6
Head banging
7
Breath holding
ITEM
NO
YES
DESCRIPTION
EXPLANATION
8
Aggression/destructiveness
9
Nervous habits (nail biting etc)
10
Fire play or cruelty to animals
11
Major mood swings
12
Under or over reactive to sounds
13
Under or over reactive to clothing
14
Under or over reactive to taste
15
Under or over reactive to smell
16
Any unusual fears?
Bacharach Institute for Rehabilitation, 61 W Jimmie Leeds Road, Pomona, NJ, 08234

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