# 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:** ____

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## 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:** ____