C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-19. Communication (PAST 30 DAYS) No evidence of Child has a history of Child has difficulty Child has serious communication problems communication problems but understanding or expressing communication difficulties exists. Any concerns are currently is not experiencing self through language / and is unable to age appropriate or this problems. gestures which interfere with communicate in any way information is unknown to functioning, including trouble including pointing and me. interpreting facial gestures grunting. or initiating gestures to communicate needs. Toddlers may not follow simple 1-step commands. Preschoolers may be unable to understand simple conversations or carry out step commands. If the needs / functioning fall within a shaded box, explain why: child’s III-20. Failure to Thrive (PAST 30 DAYS) No evidence of failure to Child may have experienced Child is experiencing Child may have one or more thrive or this information is past problems with growth problems in their ability to of the symptoms listed and unknown to me. and ability to gain weight maintain weight or growth. is currently at serious and is currently not Child may be below the 5th medical risk. experiencing problems. percentile for age and sex and may weigh less than 80% of their ideal weight for age, have depressed weight for height. If the needs / functioning fall within a shaded box, explain why: child’s III-21. Labor and Delivery Child and biological mother Child or mother had some Child or mother had problems Child had severe problems had a normal labor and mild problems during during delivery that resulted during delivery that have delivery or this information is delivery, but child does not in temporary functional resulted in long term unknown to me. appear affected by problems. difficulties for the child or implications for development. mother. If the needs / functioning fall within a shaded box, explain why: child’s
C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-19. Communication (PAST 30 DAYS) No evidence of communication problems exists. Any concerns are age appropriate or this information is unknown to me. Child has a history of communication problems but currently is not experiencing problems. Child has difficulty understanding or expressing self through language / gestures which interfere with functioning, including trouble interpreting facial gestures or initiating gestures to communicate needs. Toddlers may not follow simple 1-step commands. Preschoolers may be unable to understand simple conversations or carry out step commands. Child has serious communication difficulties and is unable to communicate in any way including pointing and grunting. If the child’s needs / functioning fall within a shaded box, explain why: III-20. Failure to Thrive (PAST 30 DAYS) No evidence of failure to thrive or this information is unknown to me. Child may have experienced past problems with growth and ability to gain weight and is currently not experiencing problems. Child is experiencing problems in their ability to maintain weight or growth. Child may be below the 5th percentile for age and sex and may weigh less than 80% of their ideal weight for age, have depressed weight for height. Child may have one or more of the symptoms listed and is currently at serious medical risk. If the child’s needs / functioning fall within a shaded box, explain why: III-21. Labor and Delivery Child and biological mother had a normal labor and delivery or this information is unknown to me. Child or mother had some mild problems during delivery, but child does not appear affected by problems. Child or mother had problems during delivery that resulted in temporary functional difficulties for the child or mother. Child had severe problems during delivery that have resulted in long term implications for development. If the child’s needs / functioning fall within a shaded box, explain why:
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