Form32 - [FORM 32Use the top of this page for your...

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[ FORM 32 —Use the top of this page for your letterhead.] Child Developmental History Record A. Identifications 1. Child’s name: Birthdate: Age: Person(s) completing this form: Today’s date: 2. Mother’s name: Birthdate: Home phone: Address: Currently employed: q No q Yes, as: Work phone: 3. Father’s name: Birthdate: Home phone: Address: Currently employed: q No q Yes, as: Work phone: 4. Parents are currently q Married q Divorced q Remarried q Never married q Other: Child’s custodian/guardian is: 5. Stepparent’s name: Birthdate: Home phone: Address: Currently employed: q No q Yes, as: Work phone: B. Development Please fill in any information you have on the areas listed below. 1. Pregnancy and delivery Prenatal medical illnesses and health care: Was the child premature? Weight and height at birth: Any birth complications or problems? 2. The first few months of life Breast-fed? If so, for how long? Any allergies?
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Form32 - [FORM 32Use the top of this page for your...

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