PEDS Response Forms

Child's Name:
Parent's Name:
Child's Birthday:
Child's Age:
Today's Date:
Please list any concerns about your child's learning, development and behavior.
1. Do you have any concerns about how your child talks and make speech sounds?
2. Do you have any concerns about how your child understands what you say?
3. Do you have any concerns about how your child uses his or her hands and fingers to do things?
4. Do you have any concerns about how your child uses his or her arms and legs?
5. Do you have any concerns about how your child behaves?
6. Do you have any concerns about how your child gets along with others?
7. Do you have any concerns about how your child is learning to do things for himself/herself?
8. Do you have any concerns about how your child is learning preschool or school skills?
Please list any other concerns.