Cuestionario para cuidadores Complete el cuestionario para cuidadores Caregiver Questionnaire Date MM slash DD slash YYYY Child's First Name* Child's Last Name* Date of Birth* MM slash DD slash YYYY Sex Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home Phone*Who referred child to Emerge: Phone Number*Address Reason for Referral: FAMILY INFORMATION:Parent's Name Birthdate* MM slash DD slash YYYY Occupation Cell PhonePlace of Employment Business Phone Email Address* Parent's Name Birthdate* MM slash DD slash YYYY Occupation Cell PhonePlace of Employment Business Phone Email Address With whom does child live?Biological Parent(s) Adoptive Parents Adopted at Age: Other (Specify) Health Insurance company List all other persons living in home:Name / Age / Relationship to child BIRTH INFORMATION:Any difficulties during pregnancy or delivery (Specify)Length of Pregnancy Length of Labor Birth Weight Any problems in newborn period (Specify)SCHOOL HISTORY:Please provide location and dates.Preschool or daycare Kindergarten Elementary School Present grade School Teacher PhoneIs your child in a special class or receiving any support services?Please list allDEVELOPMENTAL MILESTONES:Specify the age at which your child (leave blank if not applicable or you don’t remember):Sat without support Crept on hands & knees Walked independently Jumped Rode a tricyle Dressed independently Named simple objects Rode a bicycle (no training wheels)Used single words (e.g., no, mom, dog)Combined words (e.g. me go, daddy)Used simple questions (e.g. Where's cup?)Engaged in conversation Drew a recognizable picture Cut out a shape with scissors Do or did you have any concerns about your child's achievement of early developmental milestones? Yes No If yes, please describe:PROFESSIONAL AND MEDICAL CONTACTS:Please list any of the following with whom you have had contact concerning your child. If any of these professionals have tested your child, please include a copy of the report.PediatricianName/Address/Phone PsychologistName/Address/Phone TutorName/Address/Phone Occupational TherapistName/Address/Phone Physical TherapistName/Address/Phone Speech TherapistName/Address/Phone NeurologistName/Address/Phone Other (specify)Name/Address/Phone List any medications that your child is currently taking:List any allergies your child has (including food):Has your child had any surgeries? If yes, what type and when (e.g. tonsillectomy, tube placement, etc.)?Has your child’s hearing been tested (when and results):Has your child‘s vision been tested (when and results):ACTIVITY HISTORY :Please provide any past or current activities along with your child's reaction to the experience. Gymnastics Music Class/lessons Dance or movement class Karate or Tae Kwon Do Scouting Organized sports Other What does your child enjoy playing with? How does your child entertain him/herself?What are your concerns about your child?What have you been told by doctors, teachers and/or others about your child?Please include any diagnoses you have been given.What do you see as your child's strengths?Please describe a typical day for your child, particularly if you have any behavioral concerns.CAPTCHA