PLEASE FILL OUT THIS FORM SO WE CAN PREPARE FOR YOUR APPOINTMENTIF YOUR CHILD IS 4-5 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) Enjoys doing new things Plays “Mom” and “Dad” Is more and more creative with make-believe play Would rather play with other children than by himself Cooperates with other children Often can’t tell what’s real and what’s make-believe Talks about what she likes and what she is interested in Select AllSelect all that applyLanguage/Communication(Required) Knows some basic rules of grammar, such as correctly using “he” and “she” Sings a song or says a poem from memory such as the “Itsy Bitsy Spider” or the “Wheels on the Bus” Tells stories Can say first and last name Select AllSelect all that applyCognitive (learning, thinking, problem-solving)(Required) Names some colors and some numbers Understands the idea of counting Starts to understand time Remembers parts of a story Understands the idea of “same” and “different” Draws a person with 2 to 4 body parts Uses scissors Starts to copy some capital letters Plays board or card games Tells you what he thinks is going to happen next in a book Select AllSelect all that applyMovement/Physical Development(Required) Hops and stands on one foot up to 2 seconds Catches a bounced ball most of the time Pours, cuts with supervision, and mashes own food Select AllSelect all that applyPlease check if your child:(Required) Can’t jump in place Has trouble scribbling Shows no interest in interactive games or make-believe Ignores other children or doesn’t respond to people outside the family Resists dressing, sleeping, and using the toilet Can’t retell a favorite story Doesn’t follow 3-part commands Doesn’t understand “same” and “different” Doesn’t use “me” and “you” correctly Speaks unclearly Loses skills he once had Select AllSelect all that applyAre there any other concerns you would like to discuss?
