PLEASE FILL OUT THIS FORM SO WE CAN PREPARE FOR YOUR APPOINTMENTIF YOUR CHILD IS 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) Wants to please friends Wants to be like friends More likely to agree with rules Likes to sing, dance, and act Is aware of gender Can tell what’s real and what’s make-believe Shows more independence (for example, may visit a next-door neighbor by himself [adult supervision is still needed]) Is sometimes demanding and sometimes very cooperative Select AllSelect all that applyLanguage/Communication(Required) Speaks very clearly Tells a simple story using full sentences Uses future tense; for example, “Grandma will be here.” Says name and address Select AllSelect all that applyCognitive (learning, thinking, problem-solving)(Required) Counts 10 or more things Can draw a person with at least 6 body parts Can print some letters or numbers Copies a triangle and other geometric shapes Knows about things used every day, like money and food Select AllSelect all that applyMovement/Physical Development(Required) Stands on one foot for 10 seconds or longer Hops; may be able to skip Can do a somersault Uses a fork and spoon and sometimes a table knife Can use the toilet on her own Swings and climbs Select AllSelect all that applyPlease check if your child:(Required) Doesn’t show a wide range of emotions Shows extreme behavior (unusually fearful, aggressive, shy or sad) Unusually withdrawn and not active Is easily distracted, has trouble focusing on one activity for more than 5 minutes Doesn’t respond to people, or responds only superficially Can’t tell what’s real and what’s make-believe Doesn’t play a variety of games and activities Can’t give first and last name Doesn’t use plurals or past tense properly Doesn’t talk about daily activities or experiences Doesn’t draw pictures Can’t brush teeth, wash and dry hands, or get undressed without help Loses skills he once had Select AllSelect all that applyAre there any other concerns you would like to discuss?
