C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-15. Physical Needs (PAST 30 DAYS) Child has no physical Child has some physical Child has physical condition Child has severe physical limitations. Any concerns condition that places mild that notably impacts limitations due to multiple are age appropriate or this limitations on activities activities (blindness, physical conditions. information is unknown to (hearing, vision impairment). deafness or significant motor me. difficulties). If the needs / functioning fall within a shaded box, explain why: child’s III-16. Dental Needs (PAST 30 DAYS) No evidence of any dental Child may have some dental Dental health is interfering Child has serious dental health needs or this health needs but they are with functioning in at least health needs that require information is unknown to not clearly known at this one life domain (eating, intensive and / or extended me. time. social interaction, etc.). treatment / intervention. If the needs / functioning fall within a shaded box, explain why: child’s III-17. Daily Functioning (PAST 30 DAYS) Child has age appropriate Child has minor indications Child demonstrates Child has severe or constant self care skills. No of problems in self care moderate or routine problems in self care skills indication of deficits or this compared to same age problems in self care skills and relies on others for help information is unknown to peers, but is generally self and relies on others for help much more than is expected me. reliant. more than is expected for for his / her age group. his / her age group. If the needs / functioning fall within a shaded box, explain why: child’s III-18. Motor (PAST 30 DAYS) No evidence of fine or gross Child has some indicators Child has either fine or gross Child has significant delays motor development that motor skills are motor skill delays. in fine or gross motor problems. Any concerns are challenging and there may development or both. Delay age appropriate or this be some concern that there causes impairment in information is unknown to is a delay. functioning. me. If the needs / functioning fall within a shaded box, explain why: child’s
C. PHYSICAL / PERSONAL CARE CHARACTERISTICS (Ages Birth to 5) (Continued) III-15. Physical Needs (PAST 30 DAYS) Child has no physical limitations. Any concerns are age appropriate or this information is unknown to me. Child has some physical condition that places mild limitations on activities (hearing, vision impairment). Child has physical condition that notably impacts activities (blindness, deafness or significant motor difficulties). Child has severe physical limitations due to multiple physical conditions. If the child’s needs / functioning fall within a shaded box, explain why: III-16. Dental Needs (PAST 30 DAYS) No evidence of any dental health needs or this information is unknown to me. Child may have some dental health needs but they are not clearly known at this time. Dental health is interfering with functioning in at least one life domain (eating, social interaction, etc.). Child has serious dental health needs that require intensive and / or extended treatment / intervention. If the child’s needs / functioning fall within a shaded box, explain why: III-17. Daily Functioning (PAST 30 DAYS) Child has age appropriate self care skills. No indication of deficits or this information is unknown to me. Child has minor indications of problems in self care compared to same age peers, but is generally self reliant. Child demonstrates moderate or routine problems in self care skills and relies on others for help more than is expected for his / her age group. Child has severe or constant problems in self care skills and relies on others for help much more than is expected for his / her age group. If the child’s needs / functioning fall within a shaded box, explain why: III-18. Motor (PAST 30 DAYS) No evidence of fine or gross motor development problems. Any concerns are age appropriate or this information is unknown to me. Child has some indicators that motor skills are challenging and there may be some concern that there is a delay. Child has either fine or gross motor skill delays. Child has significant delays in fine or gross motor development or both. Delay causes impairment in functioning. If the child’s needs / functioning fall within a shaded box, explain why:
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