Emergency Contact Name
Does your child do simple household tasks?
Does you child prefer to socialize with
Do you consider your child overly shy?
Do you consider your child over-active
Has your child ever have a sleeping problem?
Has your child ever had an eating disorder?
Do you think your child is average in height
Do you think your child is average in weight
Does you child fall frequently
Does you child bump into objects around him/her
Rate your child on the following skills compared with other children the same age (circle one):
Do any foods disagree with him/her
Does he/she often have diarrhea?
Has constipation ever been much of a problem?
Was your child born with any congenital diseases or abnormalities
Is he/she doing well in school?
Radio Does he/she get along well with peers?
Circle any of the following which your child has:
Does he/she play quiet games?
Does he/she interact with peers?
Does your child participate in organized activities or take part in other classes?
Has your child ever experienced family moving
Has your child ever lived with someone other than his/her parents?
. Has your child had a traumatic experience lately?
Has your child ever experienced a death in the family?
Has your child ever experienced a parent or other family member with a long illness?
Has your child had periods of sadness or depression?