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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