Name of IFC Clinician: —Please choose an option—Andrea Peyser, LCSWBrenda Forte, LCSWDavid Szmak, PsyDJane Holzman, LCSWJanice Harris, LCSWRon Handelman, Ph.D.Therese Felcher, LCSW
Child's Name:
Grade:
D.O.B.
Source of Data: MotherFatherOther
Child is presently living with: (to select multiple items, hold down Ctrl (Windows) or Command (Mac) and click with the left mouse button)Birth MotherBirth FatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster FatherOther (Specify below):
Briefly state your view of the main problem/difficulty for your child:
Parent 1:
Relationship to child:
Occupation:
Business Phone:
Age:
Age at time patient was born:
School:
Highest Grade Completed:
Learning Problems:
Attention Problems:
Behavioral Problems:
Medical Problems:
Have any of your blood relatives experienced problems similar to those your child is experiencing? If so, describe:
Parent 2:
Name:
Medical, Social, or School Problems:
Complications:
Excessive VomitingHospitalization RequiredExcessive Staining/blood lossThreatened MiscarriageToxemiaIVF
Infections (specify):
Operations (specify):
Other illness(es) (specify):
Smoking during pregnancy:
Number of cigarettes per day:
Alcohol consumption during pregnancy:
Describe if beyond an occasional drink:
Medications during pregnancy:
X-ray studies during pregnancy:
Duration of pregnancy:
Type of Labor:SpontaneousInduced
Duration (hrs):
Type of Delivery: NormalBreechCesarean
Complications: Cord around neckHemorrhageInfant injured during deliveryOther (specify below)
Birth Weight:
JaundiceCyanosis (turned blue)Incubator Care
Number of days infant was in the hospital after delivery:
Were any of the following present – to a significant degree – during the first few years of life? If so, describe:
Did not enjoy cuddling:
Was not calmed by being held or stroked:
Difficult to comfort:
Colic:
Excessive restlessness:
Excessive irritability:
Diminished sleep:
Frequent head banging:
Difficult nursing:
Constantly into everything:
If your child’s medical history includes any of the following, please note the age when the incident or illness occurred and any other pertinent information:
Childhood diseases (describe ages and any complications):
Operations:
Hospitalization for illness:
Head injuries:
Convulsions:
With FeverWithout Fever
Coma:
Persistent high fever:
Eye problems:
Ear problems:
Allergies or Asthma:
Poisoning:
Sleep problems:
Appetite:
Approximate Height:
Approximate Weight:
Present illnesses for which the child is being treated:
Medications child is taking on ongoing basis:
If you can recall, record the age at which your child reached the following developmental milestones. If you cannot recall exactly, check the item below.
Smiled:
EarlyNormalLate
Sat without support:
Crawled:
Stood without support:
Walked without assistance:
Spoke first words:
Said phrases:
Said sentences:
Bladder trained, day:
Bladder trained, night:
Bowel trained, day:
Bowel trained, night:
Rode tricycle:
Rode bicycle (without training wheels):
Buttoned clothing:
Tied shoelaces:
Named colors:
Named coins:
Said alphabet in order:
Began to read:
Rate your child on the following skills:
Walking:
Running:
Throwing:
Catching:
Shoelace tying:
Buttoning:
Writing:
Athletic Abilities:
Excessive number of accidents compared to other children:
Do you consider your child able to understand directions and situations as well as other children his or her age? If not, why not?:
How would you rate your child’s overall level of intelligence compared to other children: Below AverageAbove AverageAverage
Were you concerned about your child’s ability to succeed in kindergarten? If so, please explain:
Rate your child's school experiences related to academic learning:
Nursery School: GoodAveragePoor
Kindergarten:GoodAveragePoor
Current Grade:GoodAveragePoor
To the best of your knowledge, at what grade level is your child functioning:
Reading:
Spelling:
Arithmetic:
Has your child ever had to repeat a grade? If so, when?
Present class placement: Regular classSpecial class (if so, specify below)
Kinds of special counseling or remedial work your child is currently receiving:
Describe briefly any academic school problems:
Rate your child's school experiences related to behavior:
Does your child’s teacher describe any of the following as significant classroom problems? Doesn’t sit in his or her seatFrequently gets up and walks around the classroomShouts out. Doesn’t wait to be called onWon’t wait his or her turnDoesn’t cooperate well in group activitiesTypically does better in a one-to-one relationshipDoesn’t respect the rights of others
Describe briefly any other classroom behavioral problems:
As best as you can recall, please use the following space to provide a general description of your child’s school progress in each grade.
Does your child seek friendships with peers?
Is your child sought by peers for friendship?
Does your child play with children primarily his or her own age?
Younger?Older?
Describe briefly any problems your child may have with peers:
What are your child’s main hobbies and interests?
What are your child’s areas of greatest accomplishment?
What does your child enjoy doing most?
What does your child dislike doing most?
What do you like about your child?
(including family doctor):
1.
2.
3.
4.
ADDITIONAL REMARKS:
Signature of Parent or Guardian
Date
By checking this box I agree that my typed name will constitute my signature.