Please fill out the form completely, remember that any information in it is important.


This form includes information that would be helpful for us in getting to know and evaluating your child. It is important for us to have this information prior to the initial assessment session to conduct our evaluation without overlooking valuable information and losing time. Please leave the parts that you do not remember or would not like to answer, blank.

Thank you for taking your time.

Name of the person filling in the form
Referring Doctor, person or facility
Referral Date
Date of Birth
Sex Male Female
School's phone number
Counselor/Classroom Teacher's name

 Information about parents
Mother's Name
Home PhoneMobile
Work phoneOccupation
Age Education
Father's Name
Home phoneMobile
Work phoneOccupation
Age Education
Parents are together divorced
Are parents alive? Yes No

Please fill in the parts below, starting from your oldest child.

 Information about siblings

Are there people who regularly provide care for the child besides the parents? Yes No
If your answer is yes, please choose one of the following options:
Babysitter takes care of the child at home Child goes to nursery/preschool Babysitter+Nursery/preschool/play group
Grandparents or other relatives take care of the child.
What are your biggest concerns about your child?
Have you applied to another facility/specialist for any reason before? Yes No
If your answer is yes, please explain
Child's Medical History
1-when child was born;Mother's age : Father's age
2-How many pregnancies did mother have?
3-Did mother have any medical issues during pregnancy? Yes No
Cevabınız Evet ise aşağıdakilerden hangileridir?
excessive nausea/morning sickness     bleeding     miscarrieage threat     Chronic conditions such as Diabetes/High blood pressure     High fever    
Trauma     Medications     Cigarette/alcohol use     Other
4-Birthwas full-term after full-term premature
5-Birth weight kg gr
6-Birth type vaginal C-section vacuum/forceps twins
7-Did child have any problems during or after birth? Yes No
If yes, please choose from the following: blood transfusion respiratory problems delayed/difficult delivery receiving oxygen other (explain)
8-Did baby undergo a blood test or any other tests after delivery? Yes No
If yes, please explain
9-How was your child as a baby in the first year? Please explain.
10-Was your child difficult to care of in the first year? Yes No
If yes, please explain
11-How long did your child have breast milk?
12-Significant problems during the first year:
Sleeping problems     frequent illness     nutrition/feeding     Breathing problems     Constipation/diarrea    
convulsion     Allergic reaction     breathing problems while crying     no problems     Other (explain)
14-Apart from the conditions above, please state any serious health issues, accidents, operations or recurring medical conditions?
15-Is your child currently on any medication?(Please write names of medications) Yes No
 Your Child's Developmental History
1-How old did your child start to hold his/her head up independently?
2-How old did your child start to sit independently?
3-How old did your child start to crawl?
4-How old did your child start to walk independently?
5-How old did your child gain toilet training?
6-When did your child use his/her first words?
7-If your child is attending school, does he/she have any problems at school? Please explain.
8-What are your child's likes?
9-What are your child's dislikes?
10-How is your child's appetite?
11-How is your child's sleep? Does he/she have any difficulties falling asleep or during sleeping? Please explain.
12-How does your child express himself/herself when he/she wants something?
13-How does your child express his/her dislikes?
14-What are your child's favorite toys?
15-Are there any toys/games that your child is afraid of or does not like?
16-What do you think your child is able to understand?
17-What may your child have difficulty understanding?
18-How does your child spend a day?
2-Do any of your close relatives have one or more of the following conditions? If so, how is that person related to your child?
1-Are mother and father related to each other? Yes No
YesNoRelationship to childExplanation
Diabetes, heart disease, etc
Mental retardation
Other disabilities
Learning disabilities
Excessive timidity
Excessive talent
Attention disorder
Late talker
Geç yürüme
Schizophrenia, depression
Pervasive Develop. Dis.
3- Have there been any negative changes in your family life during the past year, such as death, illnesses, divorce, career change or moving? Yes No
If yes, please explain
1-What are your expectations from GUNISIGI CHILD CENTER?
2-Are there any other issues that you think would be important for us to know?

Cancellation Policy

Gunisigi Child Center takes the care of our patients and their families very seriously. It is very important to us that you attend your regularly scheduled appointments. These scheduled appointments are part of a recommended treatment plan aimed at improving health, function, and the overall quality of life of our patients. Without regularly attending your scheduled appointments, the benefits of therapy will be limited.

Therefore, we call the day before your appointment to confirm your visit. any appointments not cancelled 24 hour prior to your visit will incur a cancellation fee which is half of the regular visit fee.