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What will my child learn
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Contact Info
Parent's Name
First
Last
Child's Name
First
Last
Bowel & Urine
Were all bowel movements since the last lesson normal in consistency and schedule?
(Required)
Yes
No
Was urine output normal in the hour after the last lesson?
(Required)
Yes
No
Has urination frequency/amount been normal since the last lesson?
(Required)
Yes
No
Explanation for any changes to bowel & urine:
(Required)
Diet
Has your child had anything to eat or drink in the last two hours?
(Required)
Yes
No
What has your child had to eat or drink in the last two hours? Please note when. If nothing please put N/A
(Required)
Any new foods given since the last lesson
(Required)
Yes
No
Please list any new foods given since the last lesson, as well as any reaction to the new food. If nothing please put N/A
(Required)
Sleep
Was your child’s sleep/nap schedule typical since the last lesson?
(Required)
Yes
No
Did your child fall asleep within 10 minutes of the last lesson?
(Required)
Yes
No
Explanation for any changes to sleep:
(Required)
Activity
Have there been any changes to your child’s activity/energy level or normal routine since the last lesson?
(Required)
Yes
No
Has your child been swimming or in the water (other than bathing) since the last lesson?
(Required)
Yes
No
Health
Has your child had any illnesses, seizures, fever >100.5, vomiting or skin rashes since the last lesson?
(Required)
Yes
No
Has your child had any injuries or required any medical attention (including MD appts)?
(Required)
Yes
No
Has your child taken any medication since the last lesson?
(Required)
Yes
No
Explanation for YES answers and list ALL medications:
(Required)
Child’s temperature within one hour of lesson and/or 24 hour activity notes
(Required)
Do you have any questions or concerns about your child participating in lessons today, or about your child’s progression so far?
(Required)
Yes
No
Please ask any questions or concerns you may have.
Explanation for any missed lessons/lesson notes: (Not Required)
