Dietary Considerations Action Plan

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EARLY SCREENING INVENTORY. Revised Parent Questionnaire Date_________________

CHILD INFORMATION

NAME ___________________________________________________________ Male Female

Who is completing this Mother Father Other Relative (specify)________________________

Parent Questionnaire? Guardian Caregiver Other (specify)______________________________

Other people living in the household? _______________________________________________________________

PRESCHOOL/CHILD HISTORY Has your child attended preschool/child care before? Yes No

If yes, for how long? 6 months 1 year 2 years more than 2 years

Did your child like pre-school? _____ Yes _____ No If no, state why

MEDICAL HISTORY Birth Were there any significant problems during pregnancy? Yes No

If yes, please explain: ____________________________________________________________

____________________________________________________________ Was your child more than 3 weeks premature? Yes No

If yes, how many weeks premature?____________________

Baby’s weight____________________

Did the baby stay in the hospital longer than the mother? Yes No

If yes, explain:

___________________________________________________________________________

At the time of birth, did the baby have seizures? Yes No

turn blue? Yes No

need incubator? Yes No

9/4/2018

Trevor Vazquez X

Father, 3 year-old sister

X X

7 lbs 2 oz

Child’s Health EYES Has your child ever had trouble seeing? Yes No Since birth Does your child hold books and objects close to his or her face? Yes No

Have your child’s eyes ever looked crossed? Yes No Have you ever suspected that your child has vision problems? Yes No

If yes, please explain: ______________________________________________________________________

______________________________________________________________________

EARS Has your child had frequent ear infections? Yes No Has your child ever had trouble hearing? Yes No Have you ever suspected that your child has hearing problems? Yes No

If yes, please explain: _____________________________________________________________________

_____________________________________________________________________

COORDINATION Has your child ever had trouble walking, climbing, reaching, holding on to things? Yes No

If yes, please explain:

__ ___________________________________________________________________

Has your child ever had any significant injuries or hospitalizations? If yes, please explain:

_____________________________________________ _____________________________________________ _____________________________________________

Does your child have allergies? If yes, please explain:

_____________________________________________ _____________________________________________ _____________________________________________

Please describe any other health concerns:

_____________________________________________

X X X X

X X

3 ear infections from 3-5 years-old

peanuts, milk

None

Yes

When he was 5 he had a reaction to peanut butter and was rushed to the hospital

CHILD’S DEVELOPMENT Can your child feed him or herself using a spoon and or a fork? Yes No

wash and dry his or her own hands? Yes No

help him dressing or dress with a little assistance? Yes No

separate easily from parents? Yes No

speak so that others can understand him or her? Yes No

express his or her thoughts and needs easily? Yes No

Do you have any concerns about your child’s appetite

or willingness to try different foods? Yes No

If yes, please explain:

_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

Do you have any concerns about your child’s sleeping patterns (going to bed with difficulty or walking often during the night?) Yes No If yes, please explain:

Is your child highly active? Yes No very quiet? Yes No

Is your child toilet trained during the day? Yes No in need of help with toileting? Yes No

Does your child play with blocks, boxes, cups or other construction toys without help? Yes No use crayons and/or markers to scribble or draw? Yes No listen stories being read? Yes No turn pages of a book and look at the pictures? Yes No recall stories or events? Yes No enjoy playing alone or with imaginary friends? Yes No talk to your friends/relatives who come to visit? Yes No follow simple, age-appropriate directions? Yes No

X X

he gets scared to try food because of his allergies

X X

X X X X

What are your child favorite activities?

_______________________________________________________ _______________________________________________________ _______________________________________________________

Does your child have the opportunities to play with other children? Yes No

How many hours a day does your child spend watching TV? _______________

Does he or she sit very close to the TV? Yes No Does he or she turn up the volume very high? Yes No

Are there other things you would like to tell us about your child?

_______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________

playing on the iPad, soccer

X X

Trevor is sometimes apprehensive to go to new places when we are not with him. Because of his allergy, he is afraid he will have a reaction when we are not around.