(Explain:____________________________) Yes No Please describe any current or previous speech-language, reading, or developmental evaluations or therapy: keeping your child’s current age in mind, please rate the following: Motor coordination and balance Fair Excellent Good Poor Unknown (e.g. walking, skipping, hopping, running) Hand/eye coordination Fair Excellent Good Poor Unknown (e.g. stacking blocks, coloring, writing,) Which hand does the child prefer to use? Right Left Either Vision Fair Excellent Good Poor Unknown Does the child use glasses? Yes No General behavior at home Fair Excellent Good Poor Unknown General behavior at school/ Fair Excellent Good Poor Unknown Ability to play with other children Fair Excellent Good Poor Unknown Ability to play appropriately with toys/games Fair Excellent Good Poor Unknown Fair Excellent Good Poor Unknown Ability to solve problems/puzzles Fair Excellent Good Poor Unknown Ability to respond appropriately to discipline Fair Excellent Good Poor Unknown Ability to control frustration Fair Excellent Good Poor Unknown Ability to keep attention on an activity Fair Excellent Good Poor Unknown Ability to maintain an appropriate activity Fair Excellent Good Poor Unknown Ability to not become distracted Fair Excellent Good Poor Unknown Ability to think before acting Fair (e.g. doesn’t behave impulsively) Excellent Good Poor Unknown Ability to sit still Fair (e.g. is not or restless) Excellent Good Poor Unknown “fidgety”
(Explain:____________________________) Yes No Please describe any current or previous speech-language, reading, or developmental evaluations or therapy: keeping your child’s current age in mind, please rate the following: Motor coordination and balance (e.g. walking, skipping, hopping, running) Excellent Good Fair Poor Unknown Hand/eye coordination (e.g. stacking blocks, coloring, writing,) Excellent Good Fair Poor Unknown Which hand does the child prefer to use? Right Left Either Vision Excellent Good Fair Poor Unknown Does the child use glasses? Yes No General behavior at home Excellent Good Fair Poor Unknown General behavior at school/ Excellent Good Fair Poor Unknown Ability to play with other children Excellent Good Fair Poor Unknown Ability to play appropriately with toys/games Excellent Good Fair Poor Unknown Excellent Good Fair Poor Unknown Ability to solve problems/puzzles Excellent Good Fair Poor Unknown Ability to respond appropriately to discipline Excellent Good Fair Poor Unknown Ability to control frustration Excellent Good Fair Poor Unknown Ability to keep attention on an activity Excellent Good Fair Poor Unknown Ability to maintain an appropriate activity Excellent Good Fair Poor Unknown Ability to not become distracted Excellent Good Fair Poor Unknown Ability to think before acting (e.g. doesn’t behave impulsively) Excellent Good Fair Poor Unknown Ability to sit still (e.g. is not “fidgety” or restless) Excellent Good Fair Poor Unknown
spell_2_registration_and_child_case_history_2017.docx