Demographic Information Sheet

Today's date: ____

Child's name (first/middle/last): ____

Child's date of birth (MM/ DD/YYYY): //____

If child was born premature, # of weeks premature: _________________________________

Child’s gender: Male O O Female

Child's race/ethnicity: ____

Child's birth weight (pounds/ounces): ____

Parent/primary caregiver’s name (first/middle/last): __________________________________

Relationship to child: ____

Street address: ____

City: ____

State/province: ____ ZIP/postal code: ____

Home telephone: ____ Work telephone: ____

Cell/other telephone: ____

Child's primary language: ____

E-mail address: ____

Language(s) spoken in the home: ____

ASQ-3

Child's primary care physician: ____

Clinic/location/practice name: ____

Clinic/practice mailing address: ____

City: ____

State/province: ____ ZIP/postal code: ____

Telephone: ____ Fax: ____

E-mail address: ____

Please list any medical conditions that your child has: ____

Please list any other agencies that are involved with your child/family: ____

Child ID #: ____

Date of admission to program: ____

Child’s adjusted age in months and days (if applicable): ______________________________

Program ID #: ____

Program Name: ____