Confidential Information Form For Cooperative Preschool Page 2

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INFORMATION FORM – Continued
List child’s fears
List any major changes or traumatic experiences in your child’s life: (relative’s death,
moving, divorce, hospital stay, etc.)
Please check if you have concerns about any of the following areas of development with
your child.
__ Speech/Language
__Hearing
__Dental
__Health
__Vision
__Intellectual Development
__Large or small muscle coordination
__Behavior (overly active, difficult to discipline, short attention span, aggressiveness,
overly shy or withdrawn, fearful, etc.) Please describe
Has your child been evaluated for any of the above? __Yes __No
If yes, which of the above?
By whom?
When?

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