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* 1. Demographic Info:

Instructions to Parent or Guardian: Questions P1-P19 ask about the early development and early and current home experiences of your child. Some questions require that you think as far back as to the birth of your child. Your response to these questions will help your child’s clinician better understand and care for your child. Answer each question to the best of your knowledge or memory.

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* 2. Please choose one response for each question

Early Development:

  No Yes Can't Remember Don't Know
P1. Was he/ she born before he/ she was due (premature)?
P2. Were the doctors worried about his/ her medical condition immediately after he/she was born?
P3. Did he/ she have to spend any time in a neonatal intensive care unit (NICU)?
P4. Could he/ she walk on his/ her own by the age of 18 months?
P5. Has he/ she ever had a seizure?
P6. Did he/ she ever lose consciousness for more than a few minutes after an accident?

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* 3. Early Communication:

  No Yes Can't Remember Don't Know
P7. By the time he/ she was age 2, could he/ she put several words together when speaking?
P8. Could people who did not know him/ her understand his/ her speech by the time he/ she reached age 4?
P9 Have you ever been concerned about his/ her hearing or eyesight?
P10. By the time he/ she was age 4, was he/ she interested in playing and being with other children?

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* 4. Home Environment:

  No Yes Can't Remember Don't Know
P11. has he/ she ever been admitted to the hospital for serious illness?

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* 5. Home Environment Cont'd:

  No Yes Don't Know
P12. Was there ever a time that he/ she could not live at home and someone else had to look after him/ her?
P13. Does anyone at home suffer from a serious health problem?
P14. Does anyone at home have a problem with depression?
P15. Does anyone at home regularly see a counselor, therapist, or other mental health professional?
P16. Does anyone at home have a problem with alcohol, drugs, or other substances?
P17. Would you say the atmosphere at home is usually pretty calm?

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* 6. Home Environment Cont'd:

  Less Than Once a Month Between Once a Week and Once a Month More Than Once a Week Most Days
P18. How often are there fights or arguments between people at home?
P19. How often does your child get criticized to his/ her face by other family members when he/ she is at home?

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