パソコンで入力できますChild Status Report

Applying child (1)For all of the following items, please circle (fill in)where applicable in your daily living situation.

GenderCurrent height (How many weeks into the pregnancy were they born?

(Applying child (2)Male/Female

Male/Female

Gender) cm, weight () kg Current height () weeks (() days) cm, weight () weeks () kg) days

Circumstances at birth

Normal/Cesarean section/Vacuum extraction/Suspended animation Normal/Cesarean section/Vacuum extraction/Suspended animation

Height and weight at birth

Height () cm, weight ()gYes
No(1) Name of disease ((2) Hospital (YesNo(1) Name of disease ((2) Hospital (YesNo

Are you currently visiting or consulting with ahospital or facility about a chronic illness orother problem they have?
Have they had any major illnesses in thepast?
Have they ever had convulsions or seizures?

Do they have any non-food allergies?
Are there any foods that they cannot have due
to religious reasons, illness, etc.?

))

At about () years () months old with a temperature of()℃ about () times

Have they ever experienced anaphylaxis?

Do they have any food allergies?

))

Height () cm, weight ()gYes
No(1) Name of disease ((2) Hospital (YesNo
(1) Name of disease ((2) Hospital (YesNo))))At about () years () months old with a temperature of()℃ about () times

Yes

No

Yes

No

Yes

No / Unknown

Yes

No / Unknown

Food（Food（）Yes

No / Unknown

Type of allergy（）

YesNo）
Yes

No / Unknown

Type of allergy（）

YesNo）Food（）
Yes
Yes
NoNo
Do they take any oral medications?
*If they have been prescribed an EpiPen,(1) Breakfast/lunch/dinner *Circle all that apply (1) Breakfast/lunch/dinner *Circle all that apply
please fill out this section.
(2) Drug name ()(2) Drug name ()At what age could the child hold up his/her head? At around ( ) months
At around ( ) months
Not yetNot yetAt around ( ) months
When did they start walking (walking on their own)? At around ( ) months
Not yetNot yetWhen did they start to communicate bypointing?
Do you have any concerns about theirhearing?
Do they make eye contact?

Food（At around () months

Not yet

NoYes

Yes

At around () months

Not yet

NoYes

NoYesNoCan they understand simple words that adults say(such as "come" and "please")? If "yes," please fill in □□ Japanese
Yes□ Other than Japanese

Not yet□ Japanese
Yes□ Other than Japanese

Not yetCan they say two-word sentences (give me, dogcame, etc.)? If "yes," please fill in □Yes □ Japanese

Not yetYes □ Japanese

Not yetYes

Not yetYes

Not yet

Does he/she hit, bite, or make strange
noises?

Yes

No

Yes

No

Is it hard for him/her to sit still in one
place/do they move around restlessly?

Yes

NoYes

No

Does he/she climb or jump up
suddenly?

Yes

No

Yes

NoYes

No

Fill in only if aged 3 or older

Can they say their own name?

□ Other than Japanese□ Other than Japanese

Yes
NoAre there any hospitals or facilities thatyou are currently visiting, consulting with, (1) Outpatient/Consultation *Circle either one (1) Outpatient/Consultation *Circle either oneor thinking about consulting with regarding⇒ Contents ()⇒ Contents ()their speech or development?
(2) Please circle (fill in) one of the following. (2) Please circle (fill in) one of the following.

Do they have a disability certificate or Aino Techou (certificate of the intellectuallydisabled)?

Do you have any concerns about thehealth and development of your child as
they enter nursery school?

•Developmental Counseling Room (Nanairo) •Developmental Counseling Room (Nanairo)•Health Support Center•Health Support Center•Rearing rooms (Koiwa, Shikamoto, Rinkai) •Rearing rooms (Koiwa, Shikamoto, Rinkai)•Child Development Support Center•Child Development Support Center(Hirai, Kasai, Shinozaki)(Hirai, Kasai, Shinozaki))•Other () •Other (YesNoYesNo

Disability certificate (Gradeintellectually disabled (Yes) Ai no Techou (certificate of theDegree)→ If "Yes", please specify.

No*After submission, we may ask for further interviews and documents depending on the situation of the child.

Disability certificate (Gradeintellectually disabled (Yes) Ai no Techou (certificate of theDegree)→ If "Yes", please specify.

No23.10