Hand in Hand
3860 Middle Road
Bettendorf, Iowa 52722
email us: info@handinhandqc.org

Phone: (563) 332-8010   Fax: (563) 332-7396
Health and Development Information
Parents/Guardians, please fill in as completely as possilbe.
Child's Name (include first, middle and last name):*
Preferred Name or Nickname:
Date of Birth:*     Age:*     Male*   Female*
Hair Color:    Eye Color:
Mother/Guardian Name:*
Father/Guardian Name:*
Primary email address:*
Physician Information:
Child's Doctor:*     Phone:*
Address:
Child's Dentist:*     Phone:*
Address:
General Health Information:
Is your child currently taking any medication(s)? Yes   No   If yes, please list below:
Medication Name:    Reason for taking:
Medication Name:    Reason for taking:
Medication Name:    Reason for taking:
Has your child ever been hospitalized? Yes   No   If yes, please explain with dates below:
Has your child had any surgeries? Yes   No   If yes, please list with dates below:
Does your child have any allergies? Yes   No   If yes, please specify below:
Please explain your child's developmental/learning delays
Does your child have seizures? Yes   No   What do his/her seizures "look" like?:
Does your child have any dietary restrictions due to a documented medical condition, such as diabetes or food allergies?
Please note any other food restrictions or requirements
Does your child have any other health related condition(s) we should be aware of?
Is your child verbally able to express his/her needs to others?
Please list other methods of communication your child uses
Is your child toilet trained? Yes   No   How does he/she indicate a need to use the bathroom?:
How does your child feed him/herself? (please check one):
Independently   With hand-over-hand assistance   Needs full assistance
Please describe the method you use to feed your child at home?
How does your child respond to direction/instruction?
What discipline/consequence methods are effective for your child at home?
           * - Mandatory Fields.

Hand-in-Hand is a non-profit organization that assists families with special needs. We exist to expand the capabilities, confidence and quality of life for children and young adults of all abilities by providing programs designed to encourage fun, learning and social interaction in a positive environment.