Child’s Name:__________________________________________________

Vision

            Eye Doctor:_______________________________________________

            Address:    _______________________________________________

                                _______________________________________________

            Phone #:    _______________________________________________

Date of Last Exam:_________________________________________

Visual Diagnosis:___________________________________________

Glasses/Contacts prescribed:  Yes           No

Glasses/Contacts worn:           Yes           No

Hearing

ENT:____________________________________________________

            Address:    _______________________________________________

                                _______________________________________________

            Phone #:    _______________________________________________

Date of Last Exam:_________________________________________

Audiologist:_______________________________________________

Address:    _______________________________________________

                                _______________________________________________

            Phone #:    _______________________________________________

Date of Last Exam:_________________________________________

            Degree of hearing loss:  right____________   left_____________

            Does child wear hearing aids:   right________     left________

                       cochlear implant:          right________     left________

                         If yes, cochlear implant manufacturer_____________________

Communication

          My child uses the following means of communication (please check all that apply):

            Receptive Communication:

_____ Speech

_____ Sign Language

_____Object/Picture/Symbol Communication System

_____Gestures/Cues

_____Other (Please describe)_____________________________

            _____understands less than 10 words

            _____understands 10-40 words

            _____understands 41-100 words

            _____understands 101-150 words

           _____understands 151-300 words

            _____understands over 300 words

Comments: (Please provide any helpful information regarding your child’s receptive communication)

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Expressive Communication:

_____ Speech

_____ Sign Language

_____Object/Picture/Symbol Communication System

_____Gestures/Cues

_____Other (Please describe)_____________________________

            _____understands less than 10 words

            _____understands 10-40 words

            _____understands 41-100 words

            _____understands 101-150 words

           _____understands 151-300 words

            _____understands over 300 words

Comments: (Please provide any helpful information regarding your child’s expressive communication)

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________