Did the father or mother perform genetic examinations

Do some doctors believe that handicapped is result of genetic factors

Did the mother suffer from any disease before pregnancy?

Did the mother take the necessary vitamins during pregnancy ?

Did the mother suffer any problem in uterus ?

Did the mother suffer from bleeding during pregnancy or delivery?

Did the mother expose to physical accident during pregnancy ?

Did mother expose to emotional events during pregnancy?

Did the mother expose to poison during pregnancy?

Did the mother infected with any disease during pregnancy?

Did the mother take any drugs during pregnancy ?

Did the pregnancy period uncomfortable to mother?

Did the mother suffer from maturation during pregnancy?

Pregnancy period was

عمر الام عند الولادة

Kind of delivery

Head conference on delivery

weight directly after delivery

Did the child expose lack of oxygen during delivery or after

Did he put in incubator after delivery?

Other Notes

When did the family discover the problem:

Did the child expose to severe diseases or accidents that affect on his growth :

Did the child suffer from sight problems :

Is still wear dippers:

Did he use the bathroom in accepted manner:

هل يستخدم الطفل المرحاض على نحو مقبول

Did he suffer from congenital deformaity:

Did he suffer from eating and drinking problems

Did he suffer from sleeping problems :(Day sleep – night sleep – interrupted sleep – sleeping for a long time)

Did he has allergic for special medications and food :

Did he suffer from seizures :

No of seizures

Period

kind of medication

Dose

Did he have any surgical operation:

Did he receive any medication now

تطور النمو اللغوي

تطور النمو الحركي

تطور المهارات الوظيفية والاستقلالية

تطور المهارات الاداركية والمعرفية

تطور المهارات الاكاديمية والدراسية

هل حدث للطفل إنتكاسة في أحد جوانب النمو بعد فترة نمو طبيعية

Hyperactive

Inability & distraction :

Aggressive behavior :

Obstinacy behavior :

Ignorance of people existence:

Has he random and typical movements:

Does he realized the danger:

Other behaviors:

Previous or currently health institute deal with the child:

The child response to enhancers:

More effective enhancers on child behaviors:

Most currently problems the family wants to treat:

Other Notices:

إسم المقيم وتوقيعه