Is the child adopted?
If yes, at what age did the child join the family?
Normal pregnancy and delivery?
Weight at birth
Alcohol, drugs, smoking, or any medications during this pregnancy?
If so, please list.
Did your child have jaundice?
Was oxygen or respiratory assistance required after birth?
Was your child breast fed?
Any difficulties with feeding?
Did your child have normal feeding, weight gain, sleeping cycles, and temperament?
Prenatal and Birth History
Describe mother’s general health during pregnancy (illness, accidents, prescription and non-prescription medications, etc.).
Length of pregnancy:
Child’s general health is:
Is your child on any medications?
Describe any major illnesses, accidents, surgeries, or hospitalizations the child has had.
Has your child had ear infections?
Does your child have tubes?
Please complete this section to the best of your ability.
Write the approximate age when the child began to do the following.
Does your child have any motor difficulty, such as walking or running?
Describe any feeding problems (e.g., problems with sucking, swallowing, drooling, chewing, etc.) your child has had.
Does your child:
Do you have any concerns with eating or sleeping?
How does the child interact with other family members?
How does the child interact with other children?
Do you have any other relevant concerns?
Describe any special services your child receives.
If enrolled for special education services, list main goals of the Individualized Educational Plan (IEP) or Individual Family Service Plan (IFSP).
Does your child receive any other private services?
How did you hear about The TALK Team?
The information provided in this document regarding my child is accurate and consistent to the best of my knowledge.