My name is:


This is picture of me

when I was a baby

This is me now

My birthday is:

Day / Date / Year

I live at:

Address:

My telephone number is:

Number: / 028
Mobile:

I live with my family

Here they are

This is my handprint or outline

This is my footprint or outline

My pre-school teacher is:

Name:
Tel No:

My speech therapist is:

Name:
Tel No:

My occupational therapist is:

Name:
Tel No:

My physiotherapist is:

Name:
Tel No:

I go to playgroup at:

Name:
Address:
Tel No:

My Doctor is:

Name:
Address:
Tel No:

The other doctors that I go to are:

Name:
Name:
Name:
Name:

My medical needs are:

I need: (please tick)

Help / Yes / No
Standing frame / Yes / No
Hearing aid / Yes / No

(please tick)

Glasses / Yes / No
Other
(please specify) / Yes / No
Other
(please specify) / Yes / No
Things I like to eat
Things I don’t like to eat
Allergies/intolerances
Places that I like to go
Toys that I like to play with
My favourite books are
My favourite TV programmes and videos are

My Communication

(please tick)

I am learning Makaton
I am learning PECS
I like pointing out pictures and photographs
I like songs and rhymes
My favourite songs are
I can say some words/phrases

My Self-Help Skills

Toileting

I wear a nappy
I can sit on my potty
I can ask to use my potty
I can go to the toilet by myself

Washing

(please tick)

I can wash my hands
I can wash my face
I like a bath

Eating & Drinking

I need help to eat
I can finger feed
I can use a lidded cup
I can use a trainer beaker
I can use a knife
I can use a fork
I can use a spoon
I can use a straw
I can drink from a glass or a cup

Dressing

I can help take my clothes off
I can help with putting my clothes on
I can undress myself
I can put my socks on
I can put my shoes on
I can put my coat on
I can dress myself with a little help
Other things about me
Completed by:
(Parent/Guardian)
Date: