Please print out and complete this form for each of your children. It should be send to Christopherus along with Part A of the Questionnaire.

Child's name:

Date of Birth:

Please describe your child's birth experience and any relevant early childhood information (e.g. breastfeeding, weaning, use of family bed...):

Did this child crawl? If yes, for how long? If not, what did s/he do?

Age of child when walked:

Age of child when talked:

Did s/he use a walker?

Please describe how much (if any) daily/weekly/monthly exposure your child has to TV/videos/computer:

At what age did s/he start watching these?

How often does s/he play outside?

What kind of creative play does s/he engage in?

Does your child have any learning difficulties and/or other challenges (including physical health and social and behavioral issues)? Please describe:

Can s/he read? At what age did s/he learn and how? Please describe his or her present reading level:

For how long can s/he listen to a story (i.e. without getting distracted or antsy):

For older children (Second Grade and up)

How would you describe his or her learning style?

What are his or her interests?

What kinds of crafts/handwork does s/he regularly do?

Does s/he play a musical instrument?

(all children)

What else would you like to share with us about your child?