Child and Family Information
Name of ChildGender
Date of Birth
Gestational age at birth
Home Language
Ethnicity
NHS Number
Post code
Parent(s)/Carer(s) Name(s)
Early Education Information
Early Years Setting completing form
Other setting attended
Name of key person/childminder
2 Year Lead/Manager
Date child commenced at setting
Number of hours per week at each setting
Health Information
Health Visiting Team
Health Visitor
GP Practice
Dental Practice
Immunisations outstanding
Review Information
Date Progress Review completed / Health Visitor / EY Setting
Age ASQ 3 Questionnaire completed(including ASQ-SE) / 27 month / Other
Age SOGs completed (if applicable – Health only)
Child’s Learning – based on the characteristics of effective learning (to be completed by key person)
Personal, Social and Emotional Development
Parent(s) comments
Development and Learning – current progress
Health comments (can include behaviour management, routines)
Age/Stage Band
Making Relationships / Self-confidence & Self Awareness / Managing Feelings & Behaviour
Communication and Language Development
Parent(s) comments
Development and Learning – current progress
Health Comments (can include hearing)
Age/Stage Band
Listening & Attention / Understanding / Speaking
Physical Development
Parent(s) comments
Development and Learning – current progress
Health Comments
Age/Stage Band
Moving & Handling / Health & Self-Care
Health Commentscan include: vision, height and weight, toilet training, immunisations, oral health, vitamins, vitamin D, diet and nutrition, sleep, hospital and A & E admissions
Child’s Height / Child’s Weight
Health Promotion can include: home safety, road safety, immunisations, dental care, accident prevention, management of minor illnesses, interventions, physical activity, library – reading, passive smoking, safety around pets
Family and Environmental Context
Have you considered the child’s voice? - How have you considered this?
Summary Information
ASQ 3 Summary
Area / Cut off / Total Score / Comments
Communication / 24.02
Gross Motor / 28.01
Fine Motor / 18.42
Problem Solving / 27.62
Personal-Social / 25.31
Overall Responses
- Hears Well?
Comments
- Talks like other toddlers his age?
Comments
3Understand most of what your child says? / N/A / Yes / No
Comments
4Walksruns and climbs like other toddlers? / N/A / Yes / No
Comments
5Family history of hearing impairment? / N/A / Yes / No
Comments
6Concerns about vision / N/A / Yes / No
Comments
7Any medical/health problems / N/A / Yes / No
Comments
8Concerns about behaviour / N/A / Yes / No
Comments
9Other concerns / N/A / Yes / No
Comments
ASQ SE Summary
Page / Score / Cut Off / Total Score / Comments
Page 1 / 85
(monitor 65)
Page 2
Page 3
Page 4
Overall Responses
1-34. Any concerns marked on scored items? / Yes / No
Comments
- Eating/Sleeping/Toileting concerns?
Comments
- Other worries?
Comments
Support already in place from other professional/agencies (details if applicable)
Name / Agency
Areas for Development
What parents/carers can do at home:
How the child will be supported at the education setting:
Actions for Health Visiting
Three- way meeting to be arranged / Yes / No
Names of Professionals with input into this assessment
Name / Job Title
In line with the provisions of the Data Protection Act any personal information will be held in confidence with only the necessary people able to see or use it. Under the Data Protection Act you have a right to make a formal request in writing for access to personal data held about you or your child.
We have a duty under the Children’s Act 2004 to work with parents to provide and improve services to children and young people in the area. Therefore we may also use this information where necessary with any staff who are involved in providing healthcare for your child e.g. Health Visitors, Nursing, Safeguarding etc. and other staff who may support your child’s future learning and development e.g. Early Years providers, schools, specialist support services.
Parent(s)/Carer(s) Signatures
Review Date
Review Lead
1