Early Years Education Child Information Form

EARLY YEARS EDUCATION CHILD INFORMATION FORM

Instructions: This form is to be completed with parents by the school contact person when concerns are expressed.

General Information

Child’s Name: ______Date of Birth:______

Gender: M/F Grade: ______School:______School contact:______

Father’s Name: ______Mother’s Name: ______

Home phone number: ______

Siblings (names and ages): ______

______

______

Concerns

Describe the concerns about this child:

______

______

______

______

When the concern was first noticed? By whom? ______

Have there been any changes since it was first noticed? ______

Is the child aware of the problem? ______

Prenatal and Birth History

Describe mother’s general health during pregnancy (illness, accidents, prescription and nonprescription medications, etc. ______

Length of pregnancy ______Birth weight ______
Child’s general condition at birth ______

Describe any unusual conditions or difficulties associated with the pregnancy or birth. ______

______

______

______

Medical History

Provide the approximate ages at which the child experienced any of the following illnesses or conditions:

Adenoidectomy ______Asthma ______Allergies ______

Chicken Pox ______Colds ______Convulsions ______

Croup ______Draining Ear ______Dizziness ______

Ear Infections ______Epilepsy ______Encephalitis ______

German Measles ______Headaches ______Hearing Loss ______

Heart Problems ______High Fever ______Influenza ______

Measles ______Mastoiditis ______Meningitis ______

Mumps ______Noise Exposure ______Pneumonia ______

Seizures ______Sinusitis ______Tinnitus ______

Tonsillitis ______Tonsillectomy ______Visual Problems ______

Vision Problems (Glasses) ______Dental problems ______

Food allergies______

Additional information: ______

______

Child’s general health is: ______

Is the child on any medication? If so, list. ______

______

Describe any major accidents, surgeries, or hospitalisations the child may have had. ______

Developmental History

Write the approximate age when your child began to do the following:

Crawl ______Sit ______Stand ______Walk ______

Feed Self ______Dress Self ______Use toilet ______

Does the child have any motor difficulty such as walking, running, or participating in activities that require small or large muscle coordination? ______

Describe any feeding problems (problems with sucking, swallowing, drooling, chewing, etc.)

______How does the child react to loud, new or unusual sounds? ______

Do you suspect any hearing problems? ______

General Behavior

Does the child eat well? ______Sleep well? ______

Is the child: attentive ______extremely active ______restless ______

Does the child lose his or her temper?______

How does the child interact with other family members? ______

How many hours a day does the child spend with a nanny/maid? ______

Do they discipline the child? Yes/N o ______

How do they discipline the child? e.g. raised voice, issue punishments ______

______

What does the child enjoy doing at home? ______

______

What is the child’s favorite toy or possession? ______

______

Educational History

Preschool ______Other school/s______

Teacher/s______

How is your child doing in school? In your opinion, why is this so? ______

______

What else could the school do to help your child? ______

______

______

If enrolled for Additional Educational Support Needs, list main goals of the Support Plan: ______

______

______

Additional Information

Please add any additional information you feel might be useful. ______

______

______

______

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Information from Specialists

Has the child been to see any specialists? ______

What were the other specialists’ conclusions or recommendations? ______

______Attach the most recent reports from the physician, agency, or school listed above.

Name of Physician or Specialist and contact information______

______

Signatures:

Date:

School contact: ______Position: ______Signature: ______

Parent name: ______Signature:______

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