CONNECTIONS AND CULTURE - South Dakota



FAMILY BACKGROUND INFORMATION FORMGENERAL ASSESSMENT INFORMATION ChildChild’s Name: FORMTEXT ?????DOB: FORMTEXT ?????Client Number: FORMTEXT ?????Child’s Name Verified by Birth Certificate: Yes FORMCHECKBOX No FORMCHECKBOX Alias used is applicable: FORMTEXT ?????City/State where child was born: FORMTEXT ????? Is the child a member of an affiliated tribe: Yes FORMCHECKBOX No FORMCHECKBOX Please list the tribe: FORMTEXT ????? Enrollment Number: FORMTEXT ?????What is the child’s nationality: FORMTEXT ?????How was the child’s name selected? FORMTEXT ?????CHILD DEVELOPMENT Child’s Age FORMTEXT ?????Is the child left or right handed: FORMTEXT ?????Crawling Age: FORMTEXT ?????Walking Age FORMTEXT ?????Talking Age FORMTEXT ?????Potty Training Age FORMTEXT ?????If there is/was any delay in any of these developmental milestones, was the child assessed? Please list the delay, who assessed the child, and when the child was assessed: FORMTEXT ?????Is the child physically coordinated? Yes FORMCHECKBOX No FORMCHECKBOX What is the child’s favorite food(s): FORMTEXT ?????What is the child’s favorite toys/games/movies/books/activities: FORMTEXT ?????Can the child tie his/her own shoes Yes FORMCHECKBOX No FORMCHECKBOX Can the child zip his/her own clothing: Yes FORMCHECKBOX No FORMCHECKBOX Sleep PatternsDoes the child take naps and at what time(s) of day: Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ????? Does the child sleep during the night? Yes FORMCHECKBOX No FORMCHECKBOX Does your child have nightmares? If yes, please describe and how do you comfort him/her? FORMTEXT ?????Do you have any routines you perform when the child goes to bed or has a nap (read a book, sing, say a prayer, etc.) Please list: FORMTEXT ?????Does your child require a nightlight: Yes FORMCHECKBOX No FORMCHECKBOX Does your child have a favorite pillow/blanket/stuffed toy: Yes FORMCHECKBOX No FORMCHECKBOX FORMTEXT ?????Does your child wet the bed? Yes FORMCHECKBOX NoHygieneDoes your child dress himself/herself: Yes FORMCHECKBOX No FORMCHECKBOX Does your child brush his/her teeth at least twice a day: Yes FORMCHECKBOX No FORMCHECKBOX Does your child bathe himself/herself adequately Yes FORMCHECKBOX No FORMCHECKBOX Does the child require special hygienic products? Please list: FORMTEXT ?????Social Interactions Who are the child’s peers and are they younger or older than your child (please list): FORMTEXT ?????Does the child have any pets? If so, what type of pet and what is their name: FORMTEXT ?????How does the child interact with his/her pets? FORMTEXT ?????PHYSICAL AND MENTAL HEALTH ON CHILDChildPrenatal: Mother’s age at pregnancy: FORMTEXT ????? Father’s age at pregnancy: FORMTEXT ?????Did you smoke during your pregnancy: Yes FORMCHECKBOX No FORMCHECKBOX How much: FORMTEXT ?????Did you use alcohol during your pregnancy: Yes FORMCHECKBOX No FORMCHECKBOX How often FORMTEXT ?????Did you use drugs during your pregnancy: Yes FORMCHECKBOX No FORMCHECKBOX How often FORMTEXT ?????Did you attend a prenatal class: Yes FORMCHECKBOX No FORMCHECKBOX Did you have a partner: Yes FORMCHECKBOX No FORMCHECKBOX Did you attend routine medical exams during your pregnancy? Yes FORMCHECKBOX No FORMCHECKBOX Describe any prenatal complications you had: FORMTEXT ?????Postnatal:Type of delivery (forceps, c-section, vaginal): FORMTEXT ?????Duration of labor: FORMTEXT ?????Complications of birth (breech, oxygen deprived): FORMTEXT ?????Physical problems noted at birth: FORMTEXT ?????Full term gestation: Yes FORMCHECKBOX No FORMCHECKBOX Birth weight FORMTEXT ?????Birth length FORMTEXT ?????Does the child have birth or other identifying marks (please list): FORMTEXT ?????Was your child circumcised: Yes FORMCHECKBOX No FORMCHECKBOX Was your child breast fed or formula fed (name type of formula)? FORMTEXT ?????Child’s Blood type: FORMTEXT ????? Mother’s blood type: FORMTEXT ????? Father’s blood type: FORMTEXT ?????GeneralCurrent weight: FORMTEXT ????? Current Height: FORMTEXT ????? Hair color FORMTEXT ????? Eye Color FORMTEXT ?????Immunizations current: Yes FORMCHECKBOX No FORMCHECKBOX Does the child have allergies? Please list FORMTEXT ????? How do you treat the allergies (medications, etc.) FORMTEXT ?????Does the child have/had any childhood diseases? Please list FORMTEXT ????? How is/was this being treated: FORMTEXT ?????Hospitalizations FORMTEXT ?????Surgeries FORMTEXT ?????Age of menstruation onset: FORMTEXT ?????Are/were there particular foods that the child cannot eat due to health reasons: FORMTEXT ?????Complications or other health problems FORMTEXT ?????Who takes care of the child when he/she is ill: FORMTEXT ?????Current Physician: FORMTEXT ?????Name of clinic: FORMTEXT ?????DentalHas your child had a dental exam: Yes FORMCHECKBOX No FORMCHECKBOX Please list date of last exam: FORMTEXT ?????Does your child wear/require braces: Yes FORMCHECKBOX No FORMCHECKBOX Does your child have any identified dental needs (please list): FORMTEXT ?????Current Dentist: FORMTEXT ?????Name of clinic: FORMTEXT ?????VisionHas your child had a vision exam: Yes FORMCHECKBOX No FORMCHECKBOX Please list date of last exam: FORMTEXT ?????Does your child wear/require corrective lens: Yes FORMCHECKBOX No FORMCHECKBOX Does your child have any identified vision needs (please list): FORMTEXT ?????Current Doctor: FORMTEXT ?????Name of clinic: FORMTEXT ?????HearingHas your child had a hearing test: Yes FORMCHECKBOX No FORMCHECKBOX Please list date of last exam: FORMTEXT ?????Does your child wear/require hearing aids: Yes FORMCHECKBOX No FORMCHECKBOX Does your child have any identified hearing needs (please list): FORMTEXT ?????Current Audiologist: FORMTEXT ?????Name of clinic: FORMTEXT ?????CONNECTIONS AND CULTUREHeritage and TraditionsIs there a special meaning to the family name? FORMTEXT ?????What languages are spoken in your home? FORMTEXT ?????List important milestones for children and adults in your culture/heritage? FORMTEXT ?????Are there traditional foods that your family eats? FORMTEXT ?????Which holidays/traditions do you celebrate and how do you celebrate them? FORMTEXT ?????ReligionIs there a particular faith that you practice? FORMTEXT ?????Does your child participate in the practices of this faith Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX Has your child been baptized Yes FORMCHECKBOX No FORMCHECKBOX NA FORMCHECKBOX CultureMaternal origin/ethnicity FORMTEXT ?????Paternal origin/ethnicity FORMTEXT ?????Child’s origin/ethnicity FORMTEXT ?????How much does your child know about his/her culture? FORMTEXT ?????What are the advantages to being male/female in your culture/family? FORMTEXT ?????List the different roles and duties that males and females have in your culture/family: FORMTEXT ?????Is it acceptable to be a single parent in your culture/family Yes FORMCHECKBOX No FORMCHECKBOX What type of hair cut or length is important in you culture/family? FORMTEXT ?????Would you like to be notified before cutting your child’s hair? Yes FORMCHECKBOX No FORMCHECKBOX Do extended family members/friends reside with you in your home? Please list: FORMTEXT ?????Community/Activities/HobbiesDescribe the neighborhood/community you live in (rural, urban, ethnic, etc): FORMTEXT ?????Describe the neighborhood/community you grew-up in: FORMTEXT ?????What do you like/dislike about the neighborhood/community you live in? FORMTEXT ?????Please list the activities your child is involved? FORMTEXT ?????Please list the activities you are involved in: FORMTEXT ?????What hobbies and special interests does your child have? FORMTEXT ?????What hobbies and special interests do you have? FORMTEXT ?????Does your child participate in sports? Please list: FORMTEXT ?????Moves or PlacementsBirth Home:Who lived in the home at this time? FORMTEXT ?????How long did you live in this home? FORMTEXT ?????How old was the child when you moved? FORMTEXT ?????What was their attitude about moving? FORMTEXT ?????How did the child adjust to the move? FORMTEXT ?????Did the child behave differently at this time (please describe)? FORMTEXT ?????Did the child have any traumatic experiences at this home? FORMTEXT ?????Next Move:Who lived in the home at this time? FORMTEXT ?????How long did you live in this home? FORMTEXT ?????How old was the child when he/she was moved/placed? FORMTEXT ?????What was their attitude about moving/being placed? FORMTEXT ?????How did the child adjust to the move/placement? FORMTEXT ?????Did the child behave differently at this time (please describe)? FORMTEXT ?????Did the child have any traumatic experiences at this home? FORMTEXT ?????INFORMATION ON BIOLOGICAL MOTHER AND FATHERBackground InformationMotherFatherNameAlias/Maiden NameDate of BirthClient NumberMarital StatusAddressTelephone NumberPlace of BirthRace-TribeReligionEnrollment NumberFavorite FoodsHobbies, Talents, SkillsAge at Death (if applicable)Cause of Death (if applicable)EmploymentMotherFatherCurrent EmployerType of EmploymentLength of Time at this JobMilitary ServiceDate and Place of Military ServicesEducationMotherFatherLast Grade CompletedLearning DisabilitiesName of School and LocationDiploma/GEDExtracurricular ActivitiesPhysical & Mental HealthMotherFatherPhysical HealthCurrent PhysicianWeightHeightDistinguishing Marks-TattoosCurrent Health ConditionHeart DiseaseHigh Blood PressureDiabetesCancerSeizures, Convulsions, EpilepsyCerebral PalsyParalysis or Crippling DisorderMultiple SclerosisMuscular DystrophyCleft PalateClub FootFetal Alcohol SyndromeBorn Drug AddictedADD/ADHDMental RetardationCurrent Medication Prescribed/RequiredAlcohol and Drug Alcohol Use (Y/N)Cigarette Use (Y/N)Marijuana Use (Y/N)Cocaine Use (Y/N)Methamphetamines (Y/N)Barbiturates (Y/N)Other (list)Treatment for substance abuse (type, date, facility )VisionCurrent Optometrist/Eye DoctorEye ColorCurrent Vision HealthGlassesAstigmatismFar Sighted/Near SightedCross Eyed/OtherBlindness/Serious Vision ProblemDentalCurrent Dentist/OrthodontistCurrent Dental HealthDental Problems (Y/N-describeBracesHearingCurrent AudiologistHearing Problems (Y/N-describe)Deafness/Serious Hearing ProblemsSpeech Current Speech PathologistSpeech Problems (Y/N-describe)Mute/Serious Speech ProblemsMental HealthCurrent Psychologist/Psychiatrist/CounselorCurrent Mental HealthDiagnosed Mental IllnessMedication Prescribed/RequiredThis section relates to the identified child’s siblings. Background InformationSiblingSiblingSiblingSiblingNameAlias-Maiden NameStep Sibling (Y/N)AddressPhone NumberDate of BirthPlace of BirthRaceTribeEnrollment NumberMarital StatusReligionDeceased (Y/N)Cause of DeathEmploymentSiblingSiblingSiblingSiblingCurrent EmployerType of EmploymentLength of Time at this JobMilitary ServiceDate and Place of Military ServicesEducationSiblingSiblingSiblingSiblingLast Grade CompletedLearning DisabilitiesName of School and LocationDiploma/GEDPhysical & Mental HealthSiblingSiblingSiblingSiblingPhysical HealthWeightHeightDistinguishing Marks-TattoosCurrent Health ConditionHeart DiseaseHigh Blood PressureDiabetesCancerSeizures, Convulsions, EpilepsyCerebral PalsyParalysis or Crippling DisorderMultiple SclerosisMuscular DystrophyCleft PalateClub FootFetal Alcohol SyndromeBorn Drug AddictedADD/ADHDMental RetardationCurrent Medication Prescribed/RequiredAlcohol and Drug Alcohol Use (Y/N)Cigarette Use (Y/N)Marijuana Use (Y/N)Cocaine Use (Y/N)Methamphetamines (Y/N)Barbiturates (Y/N)Other (list)Treatment for substance abuse (type, date, facility)VisionEye ColorCurrent Vision HealthGlassesAstigmatismFar Sighted/Near SightedCross Eyed/OtherBlindness/Serious Vision ProblemDentalCurrent Dental HealthDental Problems (Y/N-describeBracesHearingHearing Problems (Y/N-describe)Deafness/Serious Hearing ProblemsSpeech Current Speech PathologistSpeech Problems (Y/N-describe)Mute/Serious Speech ProblemsMental HealthCurrent Mental HealthDiagnosed Mental IllnessMedication Prescribed/RequiredINFORMATION ON EXTENDED FAMILY MEMBERSBackground InformationMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherNameAlias-Maiden NameStep Parent (Y/N)AddressPhone NumberDate of BirthPlace of BirthRaceTribeEnrollment NumberMarital StatusReligionDeceased (Y/N)Cause of DeathIndicate the name of any extended relative known to have listed condition. Physical & Mental HealthNameNameNameNamePhysical HealthHeart DiseaseHigh Blood PressureDiabetesCancerSeizures, Convulsions, EpilepsyCerebral PalsyParalysis or Crippling DisorderMultiple SclerosisMuscular DystrophyCleft PalateClub FootFetal Alcohol SyndromeBorn Drug AddictedADD/ADHDMental RetardationAlcohol and Drug Alcohol Use (Y/N)Cigarette Use (Y/N)Marijuana Use (Y/N)Cocaine Use (Y/N)Methamphetamines (Y/N)Barbiturates (Y/N)Other (list)Treatment for substance abuse (type, date, facility)VisionBlindness/Serious Vision ProblemHearingHearing Problems (Y/N-describe)Deafness/Serious Hearing ProblemsMental HealthDiagnosed Mental Illness ................
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