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If you plan to take your child to a new or different pediatrician or family physician, fill out a copy of this form before your appointment to give the new physician a quick profile of your child's health, growth, and development.

1. Evaluate. Much above average (4+), above average (3+), average (2+), below average (1+), much below average (0):
Reading Special interests
Spelling Writing
Arithmetic Athletics
Art Activity preferred
Music Activity avoided
2. What special placement or help has the child had? (Check all that apply.)
____ Upgraded ____ Remedial reading
____ Sight saving ____ RepeaterGrade: ____
____ Special class ____ Speech correction
____ Tutoring Subject: ____
3. From your observation, disregarding achievement, consider the child's abilities in the following areas:
General information
Grasp of concepts
Curiosity and desire to gain information
4. Do you feel the child is working up to mental capacity? ____ Yes ____ No

ATTENTION SPAN (Check all that apply.)
____ Listens ____ Is easily distracted
____ Observes ____ Has short attention span
____ Sticks to tasks ____ Has long attention span
____ Sustains interest in self-initiated projects

HOME BEHAVIOR (Check all that apply and
add anything you consider important.)
____ Sits fiddling with objects (fidgety) ____ Steals
____ Hums and makes odd sounds ____ Is destructive
____ Falls apart under stress ____ Is annoying
____ Has poor coordination ____ Is aggressive
____ Is restless and overactive ____ Is submissive
____ Is excitable ____ Talks excessively
____ Is inattentive ____ Talks very little
____ Has difficulty in concentration
____ Acts without thought (impulsive)
____ Is immature ____ Is fearful
____ Has temper outbursts ____ Is dependent
____ Daydreams ____ Is cooperative
____ Is sullen or sulky ____ Bites nails
____ Disturbs other children ____ Sucks thumb
____ Is quarrelsome ____ Seeks unusual amount of attention
____ Has tics (odd movements) ____ Other
____ Tells lies

GROUP BEHAVIOR (Check and answer all that apply.)
____ Enjoys companionship ____ Possesses no sense of fair play
____ Is not accepted by other children ____ Prefers solitary play
____ Teases other children ____ Prefers younger children
____ Injures other children ____ Prefers mother, father
____ Prefers to be with adults
How do classmates feel about the child?
How do members of the household feel about the child?
How do neighborhood children feel about the child?

LANGUAGE AND SPEECH (Check all that apply.)
____ Follows directions ____ Recalls new words
____ Repeats directions given ____ Enunciates clearly
____ Expresses self in sentences ____ Exhibits immature speech
____ Uses expressive vocabulary ____ Stutters

COORDINATION (Check all that apply.)
____ Is well coordinated ____ Skips
____ Runs well ____ Hops
____ Walks well ____ Rides a tricycle or bicycle
____ Draws well ____ Holds pencil correctly
____ Colors well ____ Reverses letters or words
____ Does a puzzle well ____ Draws and writes neatly
____ Writes own name well
____ Right ____ Left ____ Both

Significant injuries:
Marital problems of parents:
Changes in the household (new baby, others living in the household):
Moving to a new home:
How do the parents react to the child's failures?
What are the child's successes?
How do the parents react to the child's successes?
Are there books, a dictionary, other learning materials in the home?
____ Yes ____ No
Does the child have a fear of going to school:


Mother _____ Brothers _____
Father _____ Sisters _____
Days tardy _____ Days absent _____
Visits to the school nurse's office during the past year _____
Visits to the doctor's office during the past year _____
Is the child robust or sickly? _____
Did brothers, sisters, parents, or close relatives have an educational problem? ____ Yes ____ No If yes, what was it?
How does this child differ from other children?

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