Developmental Hx Form

DEVELOPMENTAL HISTORY

Patient's Name _______________________________________________ Date _____________

Date of Birth________________________ Age___________________ Grade ____________

Sex: Female_____ Male_____

Patient's primary language____________________

Name of person completing this form _______________________________________________

Relationship to this child _________________________________________________________

Reason for evaluation or primary concerns you have regarding your child's development: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

What do you hope to learn from this neuropsychological/psycho-educational evaluation? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

______________________________________________________________________________

Developmental History 2

FAMILY Father's name _______________________________________________ Age _____________ Father's occupation _____________________________________________________________ Highest grade completed _________________________________________________________ Mother's name _______________________________________________ Age _____________ Mother's occupation ____________________________________________________________ Highest grade completed _________________________________________________________ Does this child have other parent(s)/stepparents? ______________________________________ If yes, please provide information __________________________________________________ Name all persons living with the child: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ If your child does not live you with full time, please explain (e.g., half-time with mom; half-time with dad; mother has full custody; child does/does not see parent; legal guardian relationship): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Developmental History 3

BIRTH AND DEVELOPMENT

Birth weight: ______lbs. ______oz.

Born at ___________weeks (e.g., 39 weeks)

Child's condition at birth _________________________________________________________

Mother's condition at birth _______________________________________________________

Described any complications that occurred during pregnancy/birth: _____________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Development

At what age did this child first do the following? Please indicate year/month of age.

______________ Turn Over

______________ Walk Alone

______________ Sit Alone

______________ Understand First Words

______________ Crawl

______________ Speak First Words

______________ Stand Alone

______________ Speaks in Sentences

Problems feeding? ______________________________________________________________

When was this child toilet trained? _________________________________________________

Did bed-wetting occur after toilet training ? _______ If yes, until what age? ________________

Did bed-soiling occur after toilet training ? _______ If yes, until what age? ________________

Any medical reasons for bed-wetting/bed-soiling? _____________________________________

Developmental History 4

Has this child experienced any of the following problems? If yes, please describe.

Unclear speech

No Yes ___________________________________________________

***Did child ever receive speech or language services? No Yes

If yes, please describe:___________________________________________________________

Eating problem

No Yes ___________________________________________________

Sleep problem

No Yes ___________________________________________________

Temper tantrums No Yes ___________________________________________________

Excessive crying No Yes ___________________________________________________

Failure to thrive No Yes ___________________________________________________

Underweight/overweight problem No Yes _______________________________________

Problems separating from parents No Yes _______________________________________

Difficulty learning to ride a bike No Yes _______________________________________

Difficulty learning to throw/catch No Yes _______________________________________

Difficulty with fine motor skills No Yes _______________________________________

Difficulty with large motor skills No Yes _______________________________________

Does your child play/enjoy sports No Yes _______________________________________

***Did child ever receive speech/language therapy, occupational or physical therapy services? No Yes

If yes, please describe:___________________________________________________________

Developmental History 5

Medical History: Please describe any serious illnesses or operations (e.g., ear infections, measles,

chicken pox, meningitis, anemia, head injury, loss of consciousness, broken bones, high fever):

______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Hearing or vision problems? ______________________________________________________ Has your child ever had a head injury (with or without loss of consciousness)? No Yes If yes, please explain: _____ ______________________________________________________ Sensory Issues: Does your child have difficulties with the following: Food (textures, smell, limited variety of foods) _______________________________________ Tactile (clothing tags, fabrics, socks, shoes, clothing in general) __________________________ Auditory (loud noise, public toilets, crowds) _________________________________________ Visual (bright noise, spinning objects) ______________________________________________

Medical Care

Child's physician _______________________________________________________________

Date/reason of last visit __________________________________________________________

Has this child ever has a neurological, psychological, or psychiatric exam?

No Yes

If yes, please indicate provider's name and reason for exam _____________________________

Has your child seen or currently seeing a counselor/ therapist? No Yes _________________

If yes, counselor's name _________________________________________________________

Current medications _____________________________________________________________

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