Readiness Assessment - Kinetic Konnections

Readiness Assessment Form

Basic Information Child's Name (First, MI, Last)* Nickname Child's Date of Birth* Parent 1 (First, Last) Parent 2 (First, Last) Street Address City State Zip Code Home Phone* Parent 1 Cell Ph. Parent 2 Cell Ph.

Parents Married Separated Divorced Other

Email*

School Current School Other Preschool Current Grade Other Preschool

Pregnancy and Birth History IVF Adopted Age Surrogate mother Adoption Country Multiple Sibling Order / of Total Gestational Age at Birth Breech Age Leaving Hospital Bed Rest Easy Labor Induced Labor Hard Labor Forceps Delivery Pre/Early Labor Vacuum Delivery Pregnancy Complications or Accidents Complications at Birth - Mother

Infant Health Ear Infections Tubes in Ears (Age) High Fever (Age) Allergies (list) Reflux (Age) Hospitalization (Age) Surgery (Age) Lazy Eye (Age) Head Injury (Age) Fractures (Type/Age) Corrective Splints (Type)

Infant Development Crawling: Age (months) Crawling: Unusual Aspects Stand/Walk: Age (months) Stand/Walk: Unusual Aspects First Words: Age (months) First Words: Unusual Aspects Simple Sentences: Age (months) Simple Sentences: Unusual Aspects Toilet Trained - Day: Age (months) Toilet Trained - Day: Unusual Aspects Toilet Trained - Night: Age (months) Toilet Trained - Night: Unusual Aspects