CAREGIVER FORM Please complete this form to the best of your knowledge Child’s Name: Date of Birth: Parent / Caregiver Name/s: With whom does the child live? Medical Details Known diagnosis: Medical condition: Allergy: Medication: Previous Assessments Neurological: Vision: Hearing: Occupational therapy: Speech pathology: Psychological: Genetic: Pregnancy Was the pregnancy planned? ☐ Yes How long into the pregnancy was the mother aware she was pregnant? Did the mother smoke before pregnancy? ☐ Yes Did the mother smoke during pregnancy? ☐ Yes Did the mother exercise before pregnancy? ☐ Yes Did the mother exercise during pregnancy? ☐ Yes Did the mother drink alcohol before pregnancy? ☐ Yes ☐ No ☐ No ☐ No ☐ No ☐ No ☐ No 1 Did the mother drink alcohol during pregnancy? Any problems during pregnancy? Any problems during the delivery? ☐ Yes ☐ No Developmental Milestones Age child crawled Age child walked Gross motor now (e.g., running, walking, ball skills) - delayed, average, etc Fine motor now (e.g., dressing, feeding, drawing) – delayed, average, etc Age child babbled: Age child spoke first words: Age child spoke in sentences: Any concerns about speech or language? Breast or bottle fed? Difficulties transitioning to solids? Difficulties sleeping in first 12 months? Sleep now? Toilet training: Any problems? Any unusual fears? Anything else? Name: Date: 2