Packet for patients five years of age and older - Atlantic Health System

Bladder trained, night
Bowel trained, day
Bowel trained, night
Rode tricycle
Point out requested body parts (where
is your nose?)
Point to ask you for something (their
cup, a toy etc.)
Point at requested pictures in a book
(Show me the baby?)
Point as if to show you something that
caught their interest, such as to a
plane or squirrel running by
Gesture to communicate, such as
raising 2 hands up to be picked up
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Has your child ever regressed or lost a milestone they previously had ? (For example stopped
saying momma, or no longer pulls self to stand etc.) Yes / No
If so when and what was it? __________________________________________________
Was your child referred to the New Jersey State Early Intervention Program? Yes / No
If so, when and what were results? __________________________________________________
Current Therapy
Does your child currently receive any of the following?
Speech/Language
Physical Therapy
Occupational Therapy
ABA
Basic Skills
Resource Room
Tutoring
Through
School
Private
How many hours/week?
9