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Developmental Survey
Please complete the following survey to help the Early Childhood Program team to learn more about your child.
Child's First Name
*
Child's Last Name
*
Sex
*
Male
Female
Other
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Parent/Guardian Name
*
Email Address
*
Current School/Day Care
Household Members
Care Experience
Child's Relationship
Biological
Adopted
Pregnancy
The following questions ask about your pregnancy. Please respond to the best of your ability.
Pregnancy Issues
Medications/Substances
Over-the-counter drugs (Tylenol, Advil, etc.)
Cigarettes
Tranquilizers
Marijuana
Antidepressants
Antibiotics
Alcohol
Amphetamines
Cocaine
None
Other
Pregnancy Duration
Labor
Spontaneous
Induced
Full Term
Premature
Vaginal
Cesarean
Birth Complications?
Child's weight
Any difficulties?
*
Hospital Stay, Child
Child's Developmental History
Sleeping
Feeding
Energy Level
Temperament
Easy
Difficult
Developmental Milestones
Please enter the approximate age when your child met the following milestones of their development
Began babbling
Spoke first words
Spoke simple sentences
Understood simple commands
Easily understood by strangers
Began to write letters
Toilet trained (day)
Toilet trained (night)
Crawled
Sat alone
Stood without support
Walked without support
Rode a tricycle
Rode a bicycle
Tied shoelaces
Medical History
Please answer the following questions about your child's medical history.
Recent Physical
-
Month
-
Day
Year
Date Picker Icon
Chronic Conditions
Specialists
Serious Illness/Accidents
Nutrition/Weight
Head Injury
Medications
Sleep Concerns
Significant Changes
Prior Evaluations
Services
Hearing
Vision
Communication Methods
Social Interactions
Speech/Language History
Child's Strengths
Physical Therapy
Occupational Therapy
Other Information
Submit
Should be Empty: