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
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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:
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