INFORMAL ASSESSMENT FOR CHILDRENS DEVELOPMENT

I. PERSONAL DATA
A. Name: _______________________________Age: ________Gender:_______
Date of Birth: __________Place of Birth: _____________Contact #: ________
Address: __________________________
Religion: ___________________________Nationality: ___________

B. FAMILY BACKGROUND
Fathers Name: ______________________________Age: _______
Birthdate: _____________Birthplace: _________________Citizenship: _______
Address: _____________________________________
Educational Attainment: __________________________
Occupation: ___________________________________

Mothers Name: ______________________________Age: _______

Birthdate: _____________Birthplace: _________________Citizenship: _______
Address: _____________________________________
Educational Attainment: __________________________
Occupation: ___________________________________

List of Siblings if any: Date of Birth

1.______________________________ ____________
2. ______________________________ ____________
3. ______________________________ ____________

C. CHILDS HISTORY
C.1 Background
Are both parents the child’s biological parents? ____________
Whom does the child most resemble? _____________
Parent’s ages at child’s birth: Father: ________ Mother: _________

C.2 Pregnancy
No. of previous pregnancy: ____________
No. of previous live birth: ______________
Was pregnancy plan? ________________
Was a boy or a girl expected? __________
Was the mother under constant pre-natal care? _________

C.3 Birth
Was the baby full term? ____________ Premature: _______
Was this a difficult labor: ____________
Was the delivery normal? ____________ Caesarian Operation: _____
When: ____________
Did the baby suffer from the lack of oxygen? __________
Did the baby cry right away? ____Did the baby appear normal at birth? ____
Weight of the baby at birth: _______
C.4 Feeding
 Did the baby suck readily? _________
Feeding: Breast: ___________ Bottle: __________ Mixed: __________
How often was baby fed? ____________
Age and method of weaning (pls indicate the kind of milk) ___________
Any allergies of milk? _________

C.5 Handling
Baby was generally fed by: _____________
Changed and handled by: ______________
When the baby cry, we usually: _________________________________
For how long baby could left alone in his/her carriage or playpen before showing
sign of distress: ______________________________________________

C.6 Physical Development

Baby sat up: __________
Got first tooth: ________
Crawled: _____________
Stood aided: __________
Stood unaided: ________
Had the child reached puberty? _________

C.7 Toilet Training

Was the child toilet-trained? ___________
Age training began: ________________
What sign does the child give when he needs to use the bathroom?
_______________________________________________________

II. SCREENING

A. Instructions: Write the observed behaviors. Use different tools and activity
sheets for this component.

A.1 PHYSICAL DEVELOPMENT

A.2 COGNITIVE DEVELOPMENT

A.3 COMMUNICATION, LANGUAGE AND SPEECH DEVELOPMENT

A.4 SOCIAL OR EMOTIONAL DEVELOPMENT

A.5 ADAPTIVE BEHAVIOR

B. FINDINGS

C. DIAGNOSIS

C.1 OBSERVED BEHAVIORS

C.2 FINDINGS

C.3 RECOMMENDATION