I. Identifying Information
Please list the names, ages, and dates-of birth of the client’s (your child’s) siblings:
Were there any complications during pregnancy and/or delivery (such as hypertension/toxemia/pre-eclampsia and/or eclampsia (seizures), prematurity, maternal Lyme disease, or infection)?
IV. Postnatal Period and Infancy
V. Developmental Milestones
Has he had any chronic health problems (e.g., asthma, allergies, diabetes, heart condition)? If yes, please specify the onset, duration, and any residual problems as a result of the condition:
VII. Educational and Learning Concerns