Sample form
Child Status Report
For all of the following items, please circle (fill in)where applicable in your daily living situation.

Applying child (1)Applying child (2)Male/Female
GenderMale/Female
GenderCurrent height (××) cm, weight (××) kg Current height ( ××) cm, weight (××) kg(䚷䚷䚷䚷)×× weeks (䚷䚷䚷䚷)×× days(䚷䚷䚷䚷)×× weeks (䚷䚷䚷䚷)×× days

How many weeks into the pregnancy were they born?
Circumstances at birth

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

Height and weight at birth

Height (䚷䚷䚷)Height (䚷䚷䚷)×× cm, weight (䚷䚷䚷)×× g×× cm, weight (䚷䚷䚷)×× gYes
YesNoNo)(1) Name of disease (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷 ) (1) Name of disease (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷×××××(2) Hospital (䚷䚷䚷䚷䚷䚷䚷䚷䚷㻌㻌䚷䚷䚷䚷䚷䚷䚷䚷䚷) (2) Hospital (䚷䚷䚷䚷䚷䚷䚷䚷䚷㻌㻌䚷䚷䚷䚷䚷䚷䚷䚷䚷)⅟ⅉ Hospital
Yes
Yes
NoNo
(1) Name of disease (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷 ) (1) Name of disease (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷㻌䚷䚷 )(2) Hospital (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷) (2) Hospital (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷 )YesNoYesNoAre 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?

At about (䚷䚷䚷䚷) years (䚷䚷䚷䚷) months old with a temperature of(䚷䚷䚷䚷 ႏDERXW 䚷䚷䚷䚷) times

Have they ever experienced anaphylaxis?

Do they have any food allergies?
Do they have any non-food allergies?

Yes

NoYes

No / Unknown

Food䠄䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䠅
Yes
Yes

Yes

NoYes

No / Unknown

Food䠄䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䠅
ShrimpYes

No / Unknown

Type of allergy䠄䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䠅Are there any foods that they cannot have due
to religious reasons, illness, etc.?

At about (䚷䚷䚷䚷)
years
months old with a temperature ofᾀᴾᾂ (䚷䚷䚷䚷)
ᴾᴾᴾᴾᴾ
ᴾᴾᴾ(䚷䚷䚷䚷䚷䚷䚷䚷) times
39.1 ႏDERXWᾀNo / Unknown

Type of allergy䠄䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䠅house dust
Yes

NoNo

Food䠄䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䠅Food䠄䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䠅
Yes
Yes
NoNo
Do they take any oral medications?
If you are not sure if your child has*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 (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷) any allergies,
magnesium oxide(2) Drug name (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷)please put a "O" in the "Unknown"
At what age could the child hold up his/her head? At around (䚷䚷) months
At around (䚷䚷)Not yetNot yet≖ months
At around (䚷䚷)column.
When did they start walking (walking on their own)? At around (䚷䚷) months
Not yetNot yet12 months
When did they start to communicate by
If your child has any allergies,
Ataround(䚷䚷)monthsAt around (䚷䚷) months
NotyetNot yet14pointing?
lease put a "O" in the "Yes"Do you have any concerns about their
NoNo
Yes
Yes
column and indicate the type.
hearing?
Yes
Do they make eye contact?
Yes
NoNo
Not yet䚷YesƑ JapaneseƑ Other than Japanese

Not yet䚷Yes Ƒ JapaneseƑ Other than Japanese

Not yetNot yetYes

Not yet䚷Yes Ƒ JapaneseƑ Other than Japanese
Yes

Not yet

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

Yes

No

Yes

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

Yes

NoYes

No

Does he/she climb or jump up
suddenly?

YesNoYes

No

Yes

No

Can they understand simple words that adults say
VXFKDVFRPHDQGSOHDVH ",I\HVSOHDVHILOOLQƑ䚷Yes

Can they say two-word sentences (give me, dog
FDPHHWF ",I\HVSOHDVHILOOLQƑ

Fill in only if aged 3 or older

Can they say their own name?

Ƒ JapaneseƑ 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 䚷䚷䋻 Contents (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷)䚷䚷䋻 Contents (䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷)
delay in speech development
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?

䚷•Developmental Counseling Room (Nanairo) 䚷•Developmental Counseling Room (Nanairo)䚷•Health Support Center䚷•Health Support Center䚷•Rearing rooms (Koiwa, Shikamoto, Rinkai) 䚷•Rearing rooms (Koiwa, Shikamoto, Rinkai)
䚷•Child Development Support Center䚷•Child Development Support Center(Hirai, Kasai, Shinozaki)(Hirai, Kasai, Shinozaki)䚷•Other (䚷䚷䚷䚷䚷㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷) 䚷•Other (䚷䚷䚷䚷䚷㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌㻌䚷䚷䚷䚷䚷䚷䚷䚷䚷䚷)
YesNoYesNo
Disability certificate (Gradeintellectually disabled (Yes) Ai no Techou (certificate of theDegree)ĺ,I<HVSOHDVHVSHFLI\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)ĺ,I<HVSOHDVHVSHFLI\NoThe doctor told me at a routine
checkup that their speech is delayed.
23.10

If you are consulting about theirspeech or development, pleasealso fill in (1) and (2).