CHILD CASE
STUDY FORM
NAME OF
CHILD________________________________________________________________
AGE:
_______________________________ BIRTH DATE: ____________________
PHYSICAL DESCRIPTION;
HEIGHT: _________
PERCENTILE: ________ WEIGHT: ________ PERCENTILE:
_________
BRIEF OVERALL
PHYSICAL DESCRIPTION: _______________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
LARGE MOTOR SKILLS (5 SPECIFIC EXAMPLES OF EACH):
SMALL MOTOR SKILLS
(5 SPECIFIC EXAMPLES OF EACH):
COGNITIVE SKILLS:
LIST ONE EXAMPLE
THAT INDICATED THE CHILD WAS THINKING ABOUT WHAT WAS GOING ON.
LIST ONE EXAMPLE OF
THE CHILD’S ABILITY TO FORM CONCEPTS OR IDEAS ABOUT 5 OF THE FOLLOWING: SHAPES, COLOR, SIZE, SPACE, WEIGHT, NUMBERS,
TIME, ORDERING, GROUPING, SELF-IMAGE.
________________________________________________________________________
2. ________________________________________________________________________
________________________________________________________________________
3. ________________________________________________________________________
________________________________________________________________________
4. ________________________________________________________________________
________________________________________________________________________
5.
________________________________________________________________________
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LANGUAGE SKILLS (5
TYPICAL EXAMPLES OF THE CHILD’S SPEECH—USE DIRECT QUOTES!)
________________________________________________________________________
LIST ONE EXAMPLE OF
A SPECIFIC SITUATION THAT ENCOURAGED THE CHILD TO WANT TO LEARN LANGUAGE.
LIST ONE EXAMPLE OF
A SPECIFIC ACTION OF AN ADULT THAT HELPED PROMOTE THE CHILD’S SPEECH AND
LANGUAGE DEVELOPMENT.
SOCIAL-EMOTIONAL SKILLS
LIST AN EXAMPLE OF
A BEHAVIOR OR SKILL THAT THE CHILD APPEARED TO BE LEARNING FROM OTHER CHILDREN.
LIST AN EXAMPLE OF
THE CHILD’S PLAY WITH OTHER CHILDREN.
LIST ONE EXAMPLE OF
EACH OF HIS/HER BEHAVIOR IN THREE OF THE FOLLOWING:
A. AGGRESSION; B. WITHDRAWAL; C. JOY; D. FRUSTRATION; E.
DEPENDENCE;
F. SATISFACTION G.
FEAR; H. FANTASY.
BEHAVIOR
SELECTED:
1.___________________________
2. __________________________
3. __________________________
BRIEFLY DESCRIBE
HOW THE CHILD SEPARATES FROM HIS/HER PARENTS AT THE BEGINNING OF THE DAY.