UPDOX - PATIENT PORTAL

Patient Name * Patient DOB *

Social and Emotional

Wants to please friends Wants to be like friends More likely to agree with rules Likes to sing, dance, and act Is aware of gender Can tell what is real and what is make-believe Shows more independence (for example, may visit a next-door neighbor by him self) (adult supervision is still needed) Is sometimes very demanding and sometimes very cooperative

Language/Communication

Speaks very clearly Tells a simple story using full sentences Uses future tense; for example; "Grandma will be here" Can say name and address

Cognitive (learning, thinking, problem-solving)

Can count 10 or more things Can draw a person with at least 6 body parts Can write some letters and numbers copies a triangle and other geometric shapes Knows about thigs used every day, like money and food

Movement/Physical Development

Can stand on one foot for 10 seconds or longer Hops; may be able to skip Can do a somersault Can use a fork and spoon and sometimes a table knife Can use the toilet on his/her own Can swing and climb Name of Parent/guardian completing form * Date completed * Electronic signature of parent/guardian completing form *