Therapy Evaluation Form Page 2

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therapy evaluation form
PREGNANCY AND BIRTH HISTORY:
1. Were there any illnesses, injuries or other complications during your pregnancy?
2. Was your pregnancy full term? If not, please give gestational age.
3. Was labor and delivery normal? What was the method of delivery?
4. Were there concerns with any developmental milestones?
Yes / No
(If yes, please explain)
5. Did you experience any complications with feeding?
Yes / No
(If yes, please explain)
6. Please list any concerns regarding your child’s eating habits.
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