Child Information Form

Present Problems
6) Has your child experienced any of the following?
School Information
1) What schools has your child attended?
Name of School
Special Education
3) Estimate grade average for each year of school:
4) Has your child experienced any of the following problems in school?
7) What are your child’s usual conduct grades?
Medical History
If yes, please list below
If yes, please list below
4) Has your child experienced any of the following?
5) Which childhood illnesses or diseases has your child had and at what age?
Developmental Information:
5) Average delays in:
Personal Information:
Nutritional Information:
Family History
4) Are there any of the following:
If yes, please explain:
9) Has anyone in the immediate family (mother, father, grandparents, aunts/uncles, siblings, etc.) ever had any of the following problems?
(I, We) understand that this information will be used in the evaluation of (my, our) child and will be included in the child’s record.

Our commitment to your privacy:

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding your child and the treatment and services we provide to him/her. We are required by law to maintain the confidentiality of health information that identifies you and your child. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your child’s PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

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