Child Developmental History
Clinician
*
Cori Perruzzi
Deb Soracco
Julia Humphries
Lindsey Matthews
Meredith Lall
Rebecca Kazlauskas
Pamela Feroleto
Victoria Simeone
Intake Department
Please select the clinician from the card given to you by the front desk:
Client Name
*
First Name
Last Name
Client ID #:
*
Adverse Prenatal/Perinatal Factors (family, health, exposures, other):
*
Characterization of Infant/Toddler:
*
Preschool Experiences (Daycare, Nursery School, Lessons):
*
Any problems with:
*
Early
Within Normal Limits
Late
Sitting
Walking
Language/Speaking
Hearing/Visual
Toilet Training
*
Yes
No
Unsure
Labor/Delivery
Eating
Sleeping
Behavior/Trantrums
Colicy
Activity Level
Separation
Enuresis/Encopreseis
Illness (i.e. Ear Infection)
Explanation:
Submit
Should be Empty: