Was pregnancy & delivery with this child normal, full term & free of complications?

Did the child crawl/creep by 8-10 months and walk by 12-18 month?

Did your child speak single words (mama, daddy, dog, etc.) by 18 months?

Did your child combine words to speak simple phrases (e.g. daddy go) by age 2?

Does your child automatically recognize all his letters and numbers?

Did your child have frequent ear infections before age three? Ear tubes?

Did he/she experience any serious accidents or illnesses that required hospitalization?

Did your child have an illness complicated by a prolonged high fever greater than 104 degrees?

Did your child have an illness complicated by a prolonged high fever greater than 104 degrees?

Does your child have any hearing loss?

Does your child sometimes have difficulty understanding what you say?

Does your child sometimes have difficulty remembering simple instructions?

Does your child now or has he/she in the past received any speech therapy?

Has your child been diagnosed with ADD or ADHD?

Have teachers suggested that your child might have ADD or ADHD?

Does your child receive any special educational services at school, such as a tutor or para, resource room, Title I, special ed, or modifications from an IEP or 504 plan?

Has your child been diagnosed with any neurological, psychological, behavioral or emotional disorders such as seizures, autism, Asperger’s Syndrome, depression, anxiety, bipolar disorder, schizophrenia, post-traumatic stress, phobias, panic or obsessive-compulsive disorders?