III-4. Communication (PAST 30 DAYS) ability to Child is able to understand Child has limited abilities to Child is unable to Child’s communicate is age others but may have limited understand others and communicate. appropriate or this ability to express him / her express him / her self. information is unknown to self. me. If the needs / functioning fall within a shaded box, explain why: child’s III-5. Self Care and Daily Living Skills (PAST 30 DAYS) self care / daily living Child requires excessive Child requires assistance Child requires complete Child’s skills appear to be age verbal prompting on self (physical prompting) on assistance on more than this appropriate or care tasks or daily living multiple self care tasks or one self care task (eating, information is unknown to skills. complete assistance on one bathing, dressing, toileting). me. self care task. If the needs / functioning fall within a shaded box, explain why: child’s C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-6. Medical Needs (PAST 30 DAYS) Child is healthy or this Child has some medical Child has chronic illness that Child has life threatening information is unknown to problems that require requires ongoing medical illness or medical condition. me / does not apply. medical treatment. intervention (diabetes, (active cancer, AIDS, etc). severe / uncontrolled asthma, life threatening allergies, HIV). List medical condition (within the last 30 days): If the needs / functioning fall within a shaded box, explain why: child’s III-7. Medical Needs Life Threatening (PAST 30 DAYS) – medical condition medical condition medical condition medical condition Child’s Child’s Child’s Child’s has no implications for may shorten life, but not until places him / her at some risk places him / her at eminent shortening his / her life or later in adulthood. of premature death before risk of death. this information is unknown he / she reaches adulthood.
III-4. Communication (PAST 30 DAYS) Child’s ability to communicate is age appropriate or this information is unknown to me. Child is able to understand others but may have limited ability to express him / her self. Child has limited abilities to understand others and express him / her self. Child is unable to communicate. If the child’s needs / functioning fall within a shaded box, explain why: III-5. Self Care and Daily Living Skills (PAST 30 DAYS) Child’s self care / daily living skills appear to be age appropriate or this information is unknown to me. Child requires excessive verbal prompting on self care tasks or daily living skills. Child requires assistance (physical prompting) on multiple self care tasks or complete assistance on one self care task. Child requires complete assistance on more than one self care task (eating, bathing, dressing, toileting). If the child’s needs / functioning fall within a shaded box, explain why: C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-6. Medical Needs (PAST 30 DAYS) Child is healthy or this information is unknown to me / does not apply. Child has some medical problems that require medical treatment. Child has chronic illness that requires ongoing medical intervention (diabetes, severe / uncontrolled asthma, life threatening allergies, HIV). Child has life threatening illness or medical condition. (active cancer, AIDS, etc). List medical condition (within the last 30 days): If the child’s needs / functioning fall within a shaded box, explain why: III-7. Medical Needs – Life Threatening (PAST 30 DAYS) Child’s medical condition has no implications for shortening his / her life or this information is unknown Child’s medical condition may shorten life, but not until later in adulthood. Child’s medical condition places him / her at some risk of premature death before he / she reaches adulthood. Child’s medical condition places him / her at eminent risk of death.
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