Child Intake Form Page 2
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4During the following periods did your child have problems with any of these?
INFANCY—first year
Did not enjoy cuddling_______________________________________________________________________
Was not calmed by being held or stroked_____________________________________________________
Difficult to comfort___________________________________________________________________________
Colic_______________________________________________________________________________________
Excessive restlessness________________________________________________________________________
Excessive irritability___________________________________________________________________________
Diminished sleep____________________________________________________________________________
Frequent head banging_____________________________________________________________________
Problems with nursing or taking bottle_________________________________________________________
Constantly into everything___________________________________________________________________
TODDLER – second to third year
Excessively active___________________________________________________________________________
Cranky/irritable_____________________________________________________________________________
Withdrawn/fearful___________________________________________________________________________
Irregular patterns of sleep, appetite, habits____________________________________________________
Was your child on time, early, or late in reaching these developmental milestones?
On time
Early
Late_______
Sat up
______________________________________________________________
Walked
______________________________________________________________
Talked
______________________________________________________________
Bladder trained--day
______________________________________________________________
Bladder trained—night
______________________________________________________________
Bowel trained—day
______________________________________________________________
Bowel trained—night
______________________________________________________________
Reading
______________________________________________________________
COMPREHENSION AND UNDERSTANDING
Do you consider your child to understand directions and situations as well as other children his or her
age?____________ If not, why not?________________________________________________________
____________________________________________________________________________________________
How would you rate your child’s overall level of intelligence compared to other children?
Below Average _________________Average __________________Above Average _________________
PRESENT MEDICAL STATUS
Height _______________________ Weight ______________________________
Present illnesses for which the child is being treated____________________________________________
Medications child is taking on ongoing basis__________________________________________________
Any physical abnormalities___________________________________________________________________
Name of your child’s pediatrician or family doctor_____________________________________________
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