SLEEP Current sleep schedule Length of time on current schedule Falls asleep easily Mood upon awakening Describe. – Yes No Takes favorite toy(s) to bed child over age 1 year – Yes No If "Yes" list toy(s): – Sleep position child under age 1 year – Note: Children under age 1 year must be placed to sleep on their back unless a written statement from the child's physician is attached. Back for children under age 1 year Side or stomach (physician statement attached) Sleep position child over age 1 year – Back Side or stomach UPDATES DIAPERING / TOILETING Diaper type Diapers provided by parent – Yes No Cloth Disposable Plastic used Always Sometimes If "Sometimes" Specify: – Highly sensitive skin Frequent diaper rash Yes No Yes No Lotions, powders or salves used Yes No If "Yes", product name(s) Specify: – Toilet training attempted Yes No If "Yes", describe routine. Type of toilet seat used at home Potty chair Special toilet seat Regular toilet seat Regular bowel movements Yes No How often. Time(s) of day: Toileting problems Yes No If "Yes" Describe. – UPDATES VERBAL COMMUNICATION Family speaks what language Specify. – English If "Other" Specify: – Child speaks in Age child began talking Words Sentences Words used to describe special needs Specify. – UPDATES Page 2 of 4
SLEEP Current sleep schedule Length of time on current schedule Falls asleep easily Yes No Mood upon awakening – Describe. Takes favorite toy(s) to bed – child over age 1 year Yes No If "Yes" – list toy(s): Sleep position – child under age 1 year Note: Children under age 1 year must be placed to sleep on their back unless a written statement from the child's physician is attached. Back for children under age 1 year Side or stomach (physician statement attached) Sleep position – child over age 1 year Back Side or stomach UPDATES DIAPERING / TOILETING Diaper – type Cloth Disposable Diapers provided by parent Yes No Plastic used Always Sometimes If "Sometimes" – Specify: Highly sensitive skin Yes No Frequent diaper rash Yes No Lotions, powders or salves used Yes No If "Yes", product name(s) – Specify: Toilet training attempted Yes No If "Yes", describe routine. Type of toilet seat used at home Potty chair Special toilet seat Regular toilet seat Regular bowel movements Yes No How often. Time(s) of day: Toileting problems Yes No If "Yes" – Describe. UPDATES VERBAL COMMUNICATION Family speaks what language – Specify. English If "Other" – Specify: Age child began talking Child speaks in Words Sentences Words used to describe special needs – Specify. UPDATES Page 2 of 4
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