Child Intake Form Page 3
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4MEDICAL HISTORY
If your child’s medical history includes any of the following, please note the age when the incident or illness
occurred and give pertinent details:
Problems with pregnancy, labor, or delivery of child___________________________________________
____________________________________________________________________________________________
Childhood diseases(describe ages and any complications____________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Operations _________________________________________________________________________________
Hospitalizations for illness/surgery_____________________________________________________________
Loss of consciousness________________________________________________________________________
Head injuries________________________________________________________________________________
Convulsions_________________________________________________________________________________
with fever____________________________________________________________________________
without fever____________________________________________________________________________
Coma______________________________________________________________________________________
Persistent high fevers_________________________________________________________________________
Eye/vision problems_________________________________________________________________________
Tics (Example: eye blinking, sniffing, any repetitive, non-purposeful movements)_________________
Ear/hearing problems________________________________________________________________________
Chronic ear infections/tubes_________________________________________________________________
Thyroid problems____________________________________________________________________________
Allergies or asthma__________________________________________________________________________
Poisoning___________________________________________________________________________________
Appetite/eating problems___________________________________________________________________
Unusual cravings____________________________________________________________________________
Speech problems___________________________________________________________________________
Sleep problems______________________________________________________________________________
Clumsy/”accident prone”____________________________________________________________________
Problems with coordination__________________________________________________________________
Problems with sexual development___________________________________________________________
SCHOOL HISTORY
Were you concerned about your child’s ability to succeed in kindergarten? If so, explain:
________________________________________________________________________________________________________
________________________________________________________________________________
To the best of your knowledge, is your child at, above, or below grade level in the following subjects:
Reading__________________ Spelling_____________________ Math____________________
Has your child ever had to repeat a grade? If so, when?______________________________________
Present class placement: Regular class_________________ Special class (Please specify)__________
____________________________________________________________________________________________
Has your child been evaluated at school for learning disabilities, emotional disturbance, academically
gifted, etc.? If so, when and with what results? _________________________________
____________________________________________________________________________________________
Kinds of special counseling or remedial work your child is currently receiving:____________________
________________________________________________________________________________________________________
________________________________________________________________________________
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