Parent Questionnaire
Pediatric Development Center of Atlanta, LLC - Online Form
Date
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Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Parent/Legal Guardian Name
*
First Name
Last Name
Phone Number
*
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Area Code
Phone Number
Email
example@example.com
Primary Care Physician
*
Primary Care Physician Phone Number
*
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Area Code
Phone Number
Siblings names/ages
*
Child's Birth weight
*
Child's Birth height
*
Length of Pregnancy (weeks)
*
Type of delivery
*
Any complications at birth for the baby
*
Treatment received by baby or mother
*
Please describe any important illnesses, injuries, or surgeries, including colic, ear or chest infections, and the ages at which they occurred
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Current medical diagnoses/conditions (ADHD, Autism, Asthma, Learning Disabilities, etc.)
*
Current medications
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Allergies
*
Dietary restrictions
*
At what age did your child?
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Age in Months
sit alone
creep/crawl
pull to stand
walk alone
babble
say first word
say two word phrases
toilet train
What Languages are spoken in the home?
Were there any unusual observations during the development of these skills such as:
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dislike of being on their stomach
not crawling on hands and knees
scooting on their bottom
not responding to sounds
not making sounds to gain attention
none of the above
Have you noticed any differences compared to your other children or peers?
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Are there any family/living situations which you think might affect your child's development or therapy?
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Are there any eating concerns?
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YES
NO
picky eater
avoidance of food textures or taste
drooling
poor control of food in mouth
Is your child currently receiving any therapy or involved in any special programs?
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What other evaluations, therapy or special programs has your child had in the past?
Is there any immediate family history of the following (please list who and explain)?
Who and explain
Premature Birth
Delay in speech/motor skills
Learning disabilities
Autism
ADHD
genetic disorders
mental health issues
Other
Please describe your concerns about your child, citing specific areas (motor weaknesses, behaviors, academic difficulty, frustrations, self-help skills, peer relations, eating
*
What would you like us to help your child with?
*
What are your goals for your child?
*
Questionnaire Completed by:
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First Name
Last Name
Signature
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