Baby TALK Parent Information Form Mom (first name) ________________________(last name) _______________________Mom’s date of birth ____________ Mom’s Address (street, city, county, zip) _________________________________________ _________________________ Phone (home) _____________________________________ (cell)_____________________________________________ Email (please print legibly) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Ethnicity (circle): White, Non-Hispanic | Black, Non-Hispanic | American Indian/Alaskan Native | Hispanic | Multiracial/Ethnic | Asian/Pacific Islander Last grade of school completed: _________ OR (circle) Current high school student | Some high school, no diploma | High school diploma/GED | Vocational School Training | Associates Degree | Some college | Bachelor’s Degree Marital Status (please circle) : Married | Single | Widowed | Divorced | Separated Dad (first name) ________________________(last name) _______________________Dad ’s date of birth _____________ Dad’s Address (street, city, county, zip) __________________________________________________________________ Phone (home) _____________________________________ (cell)_____________________________________________ Email (please print legibly) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Ethnicity (please circle): White, Non-Hispanic | Black, Non-Hispanic | American Indian/Alaskan Native | Hispanic | Multiracial/Ethnic | Asian/Pacific Islander Last grade of school completed: _________ OR (circle) Current high school student | Some high school, no diploma | High school diploma/GED | Vocational School Training | Associates Degree | Some college | Bachelor’s Degree Marital Status (please circle) : Married | Single | Widowed | Divorced | Separated Baby’s name _________________________________________ Sex (circle) Male | Female Date of birth _____________ Birth Weight ___ lb ___ oz Language spoken at home (circle): English | Spanish | Other ___________________________ Family Structure of the Baby (circle): Two Parent Home | Single Parent Home | Living with Grandparents | Living with other relatives | Living in an extended family | Living with Guardian | Living with Foster Parent | Other Other children in the Family (first name, last name) ______________________________ Date of Birth ________________ ______________________________ Date of Birth ________________ ______________________________ Date of Birth ________________ Mom’s Employment Status (circle): Unemployed/not seeking employment | Unemployed/seeking employment | Unemployed/enrolled in job training | Employed 20 hrs a week or less | Employed 20 hrs a week or more | Self -employed Dad’s Employment Status (circle): Unemployed/not seeking employment | Unemployed/seeking employment | Unemployed/enrolled in job training | Employed 20 hrs a week or less | Employed 20 hrs a week or more | Self -employed Family Range of Income per year (circle): Under 10,000 | 10,000-25,000 | 25,000-50,000 | 50,000-75,000 | 75,000-100,000 | 100,000 and over WIC eligible (circle) YES | NO Baby TALK has permission to refer me to other opportunities for my child (signature)________________________________ Baby TALK © All Rights Reserved Baby TALK Parent Interview Form Today’s date ___________________ Mom’s Full Name__________________________________________ Mom’s Date of birth________ Home Phone____________________________________________________________________________ Address_______________________________________________________________________________ Street Address ______________________________________________________________________________________ City State Zip Email (please print legibly) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Ethnicity (circle): White, Non-Hispanic | Black, Non-Hispanic | American Indian/Alaskan Native | Hispanic | Multiracial/Ethnic | Asian/Pacific Islander Last grade of school completed: _________ OR (circle) GED | High school diploma | Associate’s Degree | Some Vocational | Completed Vocational School | Some college | Bachelor’s Degree | Master’s Degree | Doctorate Degree Marital Status (please circle) : Married | Single | Widowed | Divorced | Separated Dad’s Full Name____________________________________________ Dad’s Date of birth________ Home Phone____________________________________________________________________________ Address_______________________________________________________________________________ Street Address ______________________________________________________________________________________ City State Zip Email (please print legibly) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Ethnicity (circle): White, Non-Hispanic | Black, Non-Hispanic | American Indian/Alaskan Native | Hispanic | Multiracial/Ethnic | Asian/Pacific Islander Last grade of school completed: _________ OR (circle) GED | High school diploma | Associate’s Degree | Some Vocational | Completed Vocational School | Some college | Bachelor’s Degree | Master’s Degree | Doctorate Degree Marital Status (please circle) : Married | Single | Widowed | Divorced | Separated Baby TALK Parent Interview Form Baby’s Full Name __________________________________________Baby’s Date of birth_________ Sex (circle) Male or Female Birth Weight ____lb ____oz Language spoken at home (circle): English Spanish Other________________ Family Structure of the Baby (circle): Two Parent Home | Single Parent Home | Living with Grandparents | Living with other relatives | Living in an extended family | Living with Guardian | Living with Foster Parent | Other Other children in the Family (first name, last name) _____________________________________ Date of Birth__________ _____________________________________ Date of Birth__________ _____________________________________ Date of Birth __________ Mom’s Employment Status (circle): Full time (more than 20 hours per week) | Part time (20 hours or less per week) | Student Unemployed in job training | Self-employed | Unemployed (seeking employment) | Unemployed (not seeking employment) Dad’s Employment Status (circle): Full time (more than 20 hours per week) | Part time (20 hours or less per week) | Student | Unemployed in job training | Self-employed | Unemployed (seeking employment) | Unemployed (not seeking employment) Family Range of Income per year (circle): less than 5,000 | 5,000-9,999 | 10,000-19,999 | 20,000- 29,999 | 30,000-39,999 | 40,000-49,999 | 50,000-74,999 | 75,000-99,999 | 100,000 and up WIC eligible (circle) YES | NO Baby TALK has permission to refer me to other opportunities for my child. (signature)_____________________________________________________ Baby TALK Parent Interview Form PRIMARY CAREGIVER (if other than parent) Name______________________________________________ Home Phone________________________ Address_______________________________________________________________________________ Street Address ______________________________________________________________________________________ City State Zip Highest Grade Completed in School________________________________________ Occupation_____________________________________________________________________________ Business Address__________________________________________________ Phone________________ EMERGENCY TELEPHONE NUMBERS Name Relationship to Child Phone Number _________________________________ _______________________ __________________ _________________________________ _______________________ __________________ _________________________________ _______________________ __________________ Baby TALK Parent Interview Form MEDICAL INFORMATION AND HEALTH HISTORY During this pregnancy, did mother experience any unusual illnesses, conditions, or accidents? ____ Yes ___ No (If Yes, please describe) ______________________________________________________________________________________ ______________________________________________________________________________________ Length of Pregnancy____________________________________________________________ _________ Complications during delivery? ____Yes ____ No (If Yes, please describe) ______________________________________________________________________________________ ______________________________________________________________________________________ Birth Weight____________________ Did the baby have trouble breathing? ____Yes ____ No (If Yes, please describe) ______________________________________________________________________________________ ______________________________________________________________________________________ Did the baby have feeding problems?________________________________________________________ Did the baby have seizures?_______________________________________________________________ Other problems? ____Yes ____ No (If Yes, please describe) ______________________________________________________________________________________ ______________________________________________________________________________________ Check the illnesses the child has had. Please indicate the child’s age at the last occurrence and whether or not the child was hospitalized: Illness Yes No Age Measles ____ ____ ____ Chicken Pox ____ ____ ____ Mumps ____ ____ ____ Strep Throat ____ ____ ____ Tonsillitis ____ ____ ____ Ear Infections ____ ____ ____ Seizures ____ ____ ____ Meningitis ____ ____ ____ Whooping cough ____ ____ ____ Baby TALK Parent Interview Form Were any of these illnesses followed by noticeable changes in the child’s general behavior? ____Yes ____ No (If Yes, please describe) ______________________________________________________________________________________