PLEASE FILL OUT THIS FORM SO WE CAN PREPARE FOR YOUR APPOINTMENTIF YOUR CHILD IS 3-4 YEARS OLD Name(Required) First Last Your Child's Name(Required) First Your Child's Birthday MM slash DD slash YYYY Please check what your child is consistently doing:Social and Emotional(Required) Copies adults and friends Shows affection for friends without prompting Takes turns in games Shows concern for crying friend Understands the idea of “mine” and “his” or “hers” Shows a wide range of emotions Separates easily from mom and dad May get upset with major changes in routine Dresses and undresses self Select AllSelect all that applyLanguage/Communication(Required) Follows instructions with 2 or 3 steps Can name most familiar things Understands words like “in,” “on,” and “under” Says first name, age, and sex Names a friend Says words like “I,” “me,” “we,” and “you” and some plurals (cars, dogs, cats) Talks well enough for strangers to understand most of the time Carries on a conversation using 2 to 3 sentences Select AllSelect all that applyCognitive (learning, thinking, problem-solving)(Required) Can work toys with buttons, levers, and moving parts Plays make-believe with dolls, animals, and people Does puzzles with 3 or 4 pieces Understands what “two” means Copies a circle with pencil or crayon Turns book pages one at a time Builds towers of more than 6 blocks Screws and unscrews jar lids or turns door handle Select AllSelect all that applyMovement/Physical Development(Required) Climbs well Runs easily Pedals a tricycle (3-wheel bike) Walks up and down stairs, one foot on each step Select AllSelect all that applyPlease check if your child:(Required) Falls down a lot or has trouble with stairs Drools or has very unclear speech Can’t work simple toys (such as peg boards, simple puzzles, turning handle) Doesn’t speak in sentences Doesn’t understand simple instructions Doesn’t play pretend or make-believe Doesn’t want to play with other children or with toys Doesn’t make eye contact Loses skills he once had Select AllSelect all that applyAre there any other concerns you would like to discuss?
