Infant Development Program Initial Interview

Child’s Name: (*)
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Birth Date: (*)
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Adjusted Age: (*)
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Gender: (*)
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Parent(s): (*)
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Address: (*)
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Home Telephone: (*)
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Cell Phone: (*)
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Email: (*)
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Birth History:
Please describe prenatal care: (*)
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Please describe/explain labor and delivery (NICU, natural or C-section, immediate medical attention): (*)
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Number of weeks gestation delivered at: (*)
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Child’s birth weight: (*)
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Please describe any complications after birth:
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Does your child have a diagnosis?
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Please describe your child’s delay: (*)
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Medical History:
Pediatrician: (*)
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Address: (*)
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Phone Number: (*)
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Other medical specialists:
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Current health concerns/medications: (*)
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Any surgeries/ hospitalizations (past or future):
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Allergies/asthma/respiratory problems:
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Vision screening (date and results): (*)
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Audiological screening (date and results): (*)
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Ear infections (how many since birth?):
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Overall Health is described as: (*)
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Motor Development:
At what age did your child roll? (*)
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At what age did your child crawl? (*)
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At what age did your child walk? (*)
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Does your child use any adaptive equipment/orthotics?
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What are your concerns or questions with respect to your child’s mobility: (*)
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Feeding:
Is your child currently breast feeding? (*)
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Is your child currently bottle feeding? (*)
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Describe difficulties with solids or liquids:
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Speech and Language History:
Describe any known Family History of speech and language challenges:
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Behavior and Play:
Please list your child’s siblings and ages:
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Describe your child’s interactions with family members and siblings: (*)
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Does your child participate in child playgroups or attend daycare? (*)
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Daily Routines:
What are your child’s favorite activities? (*)
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What are your child’s least favorite activities? (*)
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When left alone how does your child like to spend time? (*)
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What things does your child tend to fear/avoid? (*)
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Does your child have difficulty transitioning between tasks? (*)
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Does your child have difficulty transitioning between environments? (*)
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Self Care Skills:
Does your child dress and undress independently? Explain: (*)
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Does your child remove/put on shoes and socks independently? Explain: (*)
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Is your child eating with a spoon and/or fork? Explain: (*)
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Does your child drink out of an open mouth cup? (*)
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Does your child brush his/her teeth independently? (*)
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Is your child toileting independently? (*)
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Sensorimotor History:

Please check all that apply and leave those that are not applicable blank.

VISUAL/AUDITORY
Tends to draw some letters/numbers backward? (*)
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Seems irritated by bright lights? (*)
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Has difficulty with hand-eye coordination? (*)
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Becomes overly active when surrounded by too many stimuli? (*)
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Covers eyes or ears? (*)
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Avoids certain noises or noisy environments? (*)
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VESTIBULAR
Enjoys swings, slides, jumping on the bed? (*)
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Have good balance? (*)
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Enjoys merry-go-rounds or fast carnival rides? (*)
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Ever becomes carsick? (*)
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Jumps a lot? (*)
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Dislikes being tossed or whirled about by an adult? (*)
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Ever hesitate, or have difficulty going down stairs? (*)
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Ever hesitate, or avoid climbing or playing on equipment That is off the ground (i.e. playground ladder, tire swing etc.)? (*)
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Likes to spin or whirl more than most children? (*)
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SMELL/TASTE
Tends to explore with smell, deliberately smells objects? (*)
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Seems overly sensitive to odors? (*)
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Seems to taste flavors as well as most people? (*)
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TACTILE
Tends to examine objects thoroughly with hands? (*)
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Seems to crave being held, cuddled or touched? (*)
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Dislikes being touched unexpectedly? (*)
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Tends to wear coat when not needed? (*)
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Dislikes the texture of certain clothing? (*)
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Avoids getting hands into paste, finger paint or messy things? (*)
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Seems overactive or wiggly? (*)
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Tends to bump, hit or push others? (*)
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Will only eat foods with certain textures? (*)
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Tends not to feel pain as much as other children? (*)
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Tends to be more sensitive to pain than other children? (*)
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Difficulty tolerating teeth brushing or hair washing? (*)
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PROPRIOCEPTION AND MOTOR SKILLS
Seems weaker or stronger than others his/her age? (*)
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Frequently grasps objects too tightly? (*)
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Seems to drop things easily? (*)
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Uses both hands equally? (*)
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Prefers playground activities to table activities and crafts? (*)
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Tends to prefer table activities to more active play? (*)
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Tends to deliberately fall, tumble, or bump head? (*)
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Has difficulty trying to jump, hop or skip? (*)
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Has difficulty throwing or catching a ball? (*)
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Walks on toes, or did so when younger? (*)
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Tires easily with physical activity? (*)
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Does your child fall out of their chair often for no apparent reason? (*)
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SOCIAL
Enjoy being with other children, makes friends easily? (*)
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Tend to have trouble getting along with other children? (*)
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Tend to prefer to play alone? (*)
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Have a strong desire for routine? (*)
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Craves attention? (*)
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Lacking confidence/self-esteem? (*)
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Have strong outbursts or anger rages? (*)
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Tend to be active and aggressive? (*)
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Tend to be heedless, impulsive? (*)
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Other Information:

Please share other information that you feel is important for Jabbergym to know about your child.
Strengths: (*)
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Weaknesses: (*)
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What goals would you like to see your child accomplish through therapy? (*)
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Any other information you would like us to know about your child? (*)
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Validation:
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Testimonials

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Name: (*)

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Email: (*)

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Testimonial: (*)

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