Developmental History. Age began sitting: crawling: walking: talking: *Does your child pull up? *Crawl? *Walk with support? Any speech difficulties? Special words to describe needs Language spoken at home *Any history of colic? *Does your child use pacifier or suck thumb? *When? *Does your child have a fussy time? *When? *How do you handle this time? HEALTH Any known complications at birth? Serious illnesses and/or hospitalizations: Special physical conditions, disabilities: Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions: Regular medications: EATING HABITS Special characteristics or difficulties: *If infant is on a special formula, describe its preparation in detail: Favorite foods: Foods refused: * Is your child fed held in lap? High chair? * Does your child eat with spoon? Fork? Hands? TOILET HABITS *Are disposable or cloth diapers used? *Is there a frequent occurrence of diaper rash? *Do you use: oil: powder: lotion: other: *Are bowel movements regular? How many per day? *Is there a problem with diarrhea? Constipation? *Has toilet training been attempted? *Please describe any particular procedure to be used for your child at the center: *What is used at home? Pottychair? Special child seat? Regular seat? *How does your child indicate bathroom needs (include special words): _ Is your child ever reluctant to use the bathroom? _ Does your child have accidents? *Does your child sleep in a crib? Bed? Does your child become tired or nap during the day (include when and how long)?
Developmental History. Did you have problems in health or development during birth, infancy, childhood? ❒ Normal, Unremarkable ❒ Not Relevant ❒ Relevant ❒ Note:
Developmental History. Where there any complications with your mother’s pregnancy or with your birth, or were you born prematurely? ( ) Yes ( ) No ( ) Unsure Did you experience any difficulty learning to walk, talk, read, write or reach any other developmental milestone(s)? ( ) Yes ( ) No ( ) Unsure Was there any type of child abuse in your family? ( ) Yes ( ) No ( ) Unsure How many siblings do you have? How would you describe your childhood? Educational History Were you ever formally tested for and/or diagnosed with a learning disability? ( ) Yes ( ) No ( ) Unsure If “yes”, please explain: How many years of education have you completed? Social History Have you ever experienced a traumatic event like being robbed, assaulted, raped or having been in combat? ( ) Yes ( ) No ( ) Unsure If “yes”, please explain: Are you involved in any lawsuit or legal matter with whom you want the doctor’s help by sending reports, evaluations, etc. to an attorney or to the court? ( ) Yes ( ) No If “yes”, please explain: Have you ever had legal problems, arrests, been in jail or prison? ( ) Yes ( ) No If “yes”, please explain: Please list anything else you think is important for your provider to know about your psychological or social history: Medical History Which of the following conditions are you currently being treated or have been treated for in the past? (Please Check) General Medical:
Developmental History. Child’s Prenatal History: Were there any conception or fertility problems? Has mother had any miscarriages, still births, or abortions? Was this a planned pregnancy? Were there any complications during the pregnancy? Were there any stressors during the pregnancy? Did mother take medications, use alcohol or drugs, or smoke during the pregnancy? Please specify Any complications with labor and delivery? Child’s Infancy and early childhood: How was this child as an infant (quiet, colicky, easy, predictable, etc.)? When did your child walk? Talk Toilet Train How did/does you child handle separations? Is or was your child in daycare or sittercare? Child’s Temperament: Rate your child’s activity level: Extremely Active Very Active Active Quiet Inactive Have there been any significant changes in your child’s activity level? Rate your child’s attention span: Engrossed Long 10 ----- 5 ----- 1 Short Not able to engage How does your child respond to new people and situations? How sensitive is your child to noise, visual stimuli, rough clothing, and other sensation? How does your child express happiness? Sadness? Anger? Who in the family is your child most like? What are your child’s strengths? What are your child’s weaknesses? Child’s Educational, Vocational, and Legal History: Grade Completed: (circle) P K 1 2 3 4 5 6 7 8 9 10 11 12 + School Teacher School Counselor Does your child receive special education services? Why? Family Military History: if none Branch and Years of Service Briefly describe family involvement, at any time, with the legal system, including dates, reasons, and results) Probation Officer Telephone
Developmental History. DID YOUR BIRTH MOTHER EXPERIENCE ANY TRAUMATIC EVENTS, DEATHS OF SIGNIFICANT OTHERS OR HIGH STRESS SITUATIONS DURING HER PREGNANCY WITH YOU? IF YES DURING WHAT TRIMESTER WHAT WAS THE EVENT? _ _ _. WERE YOU A FULL TERM BABY? _ IF NO, HOW PREMATURE WERE YOU? _ WEEKS. PREGNANCY COMPLICATIONS WITH YOU (CHECK ALL THAT APPLY): ☐NONE ☐DRUG USE ☐ALCOHOL USE ☐ MENTAL ILLNESS ☐ DOMESTIC VIOLENCE/SEXUAL ASSUALT/EMOTIONAL ABUSE. HOW DO YOU DESCRIBE YOUR CHILDHOOD HEALTH? ☐NORMAL ☐FREQUENT EAR INFECTIONS/TUBES IN EARS ☐ DEVELOPMENTAL DELAY ☐HEAD INJURY(S) ☐ SCHOOL IEP ☐ ADHD/ADD ☐ SELF INJURING BEHAVIOR/SUICIDAL THOUGHTS ☐ SEIZURES ☐SIGNIFICANT INJURIES ☐HOSPITALIZATIONS ☐FREQUENT ER VISITS ☐CHRONIC/SERIOUS HEALTH PROBLEMS ☐SIGNIFICANT/UNUSUAL ILLNESSES ☐OTHER DEVELOPMENT: INFANCY: ☐NONE ☐ SLEEPING PROBLEMS ☐ DIFFICULT TO SOOTHE ☐ FEEDING PROBLEMS ☐ TOILET-TRAINING PROBLEMS ☐CHOLIC ☐OTHER: DELAYED MILESTONES: ☐NONE ☐SPEECH ☐ TOLERATING SEPARATION ☐ BODY CONTROL ☐ PLAYING COOPERATIVELY ☐ ROLLING OVER ☐ BLADDER CONTROL ☐ BOWEL CONTROL ☐ RIDING TRICYCLE/BICYCLE ☐SITTING ☐ STANDING ☐ WALKING ☐ DRESSING SELF ☐ PERSONAL HYGIENE ☐ FEEDING SELF ☐ ENGAGING PEERS/MAKING FRIENDS ☐ READING ☐OTHER: _
Developmental History. Pregnancy Delivery Infancy (developmental milestones) Middle childhood (developmental milestones) Young adulthood (developmental milestones)
Developmental History. Have there been any developmental delays? Have there been any periods of rapid weight gain or weight loss? Milestone Age Milestone Age Supports self in standing position Xxxxxx trained Weaned off breast milk Ties shoes First Tooth Dresses without help Crawls Hits Puberty First word (besides mama, dada) First menstruation Walks Nutrition and Lifestyle Was/is the child breastfed? Y/N For how long? Was the child fed formula? Y/N Type (milk, soy, other): At what age was the formula was introduced?: Were/is there any feeding difficulties? Did the child ever have any difficulty gaining weight? Y/N What foods were introduced before 6 months? What foods were introduced between 6-12 months? Did the child react to any of the new foods introduced? Are there any nutritional restrictions (due to ethnicity, ethics, religion, etc.)? If applicable, please indicate the child’s frequency and intake of the following substances: Pop: Typical diet: Water: Caffeine (incl. Chocolate) Breakfast: Lunch: Dinner: Snacks: Beverages: What is the sleeping pattern of the child? Are there any difficulties sleeping? How regularly does the child get exercise? Are there any toxins or other hazards to which the child is regularly exposed?
Developmental History
