Is your child currently taking any medication? ( ) Yes ( ) No If so, please explain ___________________ Medication Dosage Frequency of Reason for Meds Administration Is there a history of speech and language problems or learning disabilities in other family members? ( ) Yes ( ) No If yes, please explain: DEVELOPMENTAL HISTORY Neonatal: (first 30 days of life): A. Cyanosis (blueness) ( ) Yes ( ) No B. Oxygen needed ( ) Yes ( ) No C. Jaundice ( ) Yes ( ) No D. Paralysis ( ) Yes ( ) No E. Infection ( ) Yes ( ) No F. Convulsions ( ) Yes ( ) No G. Please tell us what details you remember about any of the above problems: Was feeding a problem ( ) Yes ( ) No If yes please describe: Does your child have trouble: swallowing? ( ) Yes ( ) No chewing? ( ) Yes ( ) No does he/she drool? ( ) Yes ( ) No Have food allergies: ( ) Yes ( ) No If yes please list: Infancy through Preschool (0 through 5 years): Did your child meet his/her developmental milestones (first word, first steps, solid foods, etc.) at ( ) Yes ( ) No the expected ages? If no, please explain: MEDICAL HISTORY A. List any other specific illnesses not previously mentioned and at what age they occurred:
Is your child currently taking any medication? ( ) Yes ( ) No If so, please explain ___________________ Medication Dosage Frequency of Administration Reason for Meds Is there a history of speech and language problems or learning disabilities in other family members? ( ) Yes ( ) No If yes, please explain: DEVELOPMENTAL HISTORY Neonatal: (first 30 days of life): A. Cyanosis (blueness) ( ) Yes ( ) No B. Oxygen needed ( ) Yes ( ) No C. Jaundice ( ) Yes ( ) No D. Paralysis ( ) Yes ( ) No E. Infection ( ) Yes ( ) No F. Convulsions ( ) Yes ( ) No G. Please tell us what details you remember about any of the above problems: Was feeding a problem ( ) Yes ( ) No If yes please describe: Does your child have trouble: swallowing? ( ) Yes ( ) No chewing? ( ) Yes ( ) No does he/she drool? ( ) Yes ( ) No Have food allergies: ( ) Yes ( ) No If yes please list: Infancy through Preschool (0 through 5 years): Did your child meet his/her developmental milestones (first word, first steps, solid foods, etc.) at the expected ages? ( ) Yes ( ) No If no, please explain: MEDICAL HISTORY A. List any other specific illnesses not previously mentioned and at what age they occurred: