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Developmental History Form -114300304165Date Form Completed: _____________ Person Completing the Form: ______________________________ Name and relationship to clientClient’s Name: ____________________________________ Sex: M / F Date of Birth: ________________Address: __________________________________________________________________________________StreetCityStateZipPhone Number: _________________________ Email Address: _________________________________00Date Form Completed: _____________ Person Completing the Form: ______________________________ Name and relationship to clientClient’s Name: ____________________________________ Sex: M / F Date of Birth: ________________Address: __________________________________________________________________________________StreetCityStateZipPhone Number: _________________________ Email Address: _________________________________REASONS FOR EVALUATIONPlease list the reason(s) the client is being referred for the evaluation:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________When did these problems begin?What are you goals for this evaluation?Has the client ever received the diagnosis of an autism spectrum disorder? FORMCHECKBOX Yes FORMCHECKBOX No If yes, in what month & year _________ and by whom _________________________________________FAMILY INFORMATIONMother/Guardian Name: ____________________________________ Education: ______________________Occupation: ________________________________________________ FORMCHECKBOX Full-time FORMCHECKBOX Part-timeFather/Guardian Name: ______________________________________ Education: _____________________ Occupation: ________________________________________________ FORMCHECKBOX Full-time FORMCHECKBOX Part-timeParents are:Child lives with: FORMCHECKBOX Married FORMCHECKBOX Biological Mother FORMCHECKBOX Unmarried, Living Together FORMCHECKBOX Biological Father FORMCHECKBOX Never Married, Living Together FORMCHECKBOX Step-parent FORMCHECKBOX Separated FORMCHECKBOX Adoptive Parent (specify) _______________ FORMCHECKBOX Divorced FORMCHECKBOX Grandparent FORMCHECKBOX Mother Deceased FORMCHECKBOX Legal Guardian (specify) ________________ FORMCHECKBOX Father Deceased FORMCHECKBOX Other (specify) ________________Sibling InformationName of siblingSexAgeDifferentFather?DifferentMother?List any health/behavior/ learning problemsLives with child? FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX NHow well does your child get along with his/her siblings? FORMCHECKBOX Very Well FORMCHECKBOX Good FORMCHECKBOX Average FORMCHECKBOX Fair FORMCHECKBOX Poor Is English the client’s primary speaking language: FORMCHECKBOX Yes FORMCHECKBOX NoIf no, what is the client’s primary language: ______________________________________________________What is the client’s secondary language: _________________________________________________________Child Care and DisciplineWho is primarily responsible for the client’s care? FORMCHECKBOX Mother FORMCHECKBOX Father FORMCHECKBOX Both FORMCHECKBOX Other:___________Who is mainly in charge of discipline in the home? FORMCHECKBOX Mother FORMCHECKBOX Father FORMCHECKBOX Both FORMCHECKBOX Other:_________Please describe discipline techniques: ________________________________________________________________________________________________________________________________________________FAMILY PSYCHIATRIC HISTORYCondition/DisorderMother Father BrotherSisterGrandparentAunt/UncleOther Close RelativesAlcoholismAnxiety ADHD/ADDAutism Spectrum DisorderBipolar DisorderDepressionEpilepsy/Seizure DisorderGenetic ConditionHospitalized for Emotional ProblemsIntellectual disabilityJail Time/IncarcerationLanguage disorderLearning Disability Motor or Vocal TicsPsychosis or SchizophreniaSpecial EducationSubstance AbuseSuicidal Ideation/AttemptPREGNANCY AND BIRTH HISTORYParental ages when client was born: Mom ___________ Dad ___________Was this pregnancy full term? FORMCHECKBOX Yes FORMCHECKBOX No If not, how many weeks before or after the expected due date was the baby born? _____ weeks FORMCHECKBOX BEFORE FORMCHECKBOX AFTER due date Pregnancy number: 1st, 2nd, 3rd, 4th, other ____ Totals: # of pregnancies ______ # of miscarriages ______Was this a multiple birth? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UK ; if yes: FORMCHECKBOX Twins FORMCHECKBOX Triplets FORMCHECKBOX QuadrupletsWere the babies identical? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UK (unknown)Please describe any problems that occurred during previous pregnancies (e.g., miscarriage, premature labor and delivery, etc.): _______________________________________________________________________Mother’s health during pregnancy: FORMCHECKBOX No health problems during pregnancy FORMCHECKBOX Health during pregnancy not known FORMCHECKBOX Poor weight gain FORMCHECKBOX Severe nausea { FORMCHECKBOX with dehydration} FORMCHECKBOX Seizures FORMCHECKBOX Infections (Flu, measles, CMV) FORMCHECKBOX High blood pressure FORMCHECKBOX Eclampsia/Toxemia FORMCHECKBOX Other (specify)_____________________ FORMCHECKBOX Rh (blood group) incompatibility List medications taken during this pregnancy: _____________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________Did the mother consume more than 2 glasses of alcohol a day during this pregnancy? FORMCHECKBOX Yes FORMCHECKBOX NoDid the mother smoke during pregnancy? FORMCHECKBOX Yes FORMCHECKBOX NoDid the mother consume illegal substances during the pregnancy? FORMCHECKBOX Yes FORMCHECKBOX No Labor and Delivery: FORMCHECKBOX No problems during labor and delivery FORMCHECKBOX Not knownPlease note whether any problems occurred during labor or delivery (? all that apply): FORMCHECKBOX Excessive bleeding FORMCHECKBOX Forceps Used FORMCHECKBOX Meconium staining FORMCHECKBOX Umbilical cord around baby’s neck FORMCHECKBOX Fever or infection of mother FORMCHECKBOX Breathing difficulties of child FORMCHECKBOX Placenta previa or abruption FORMCHECKBOX Placenta (bag of water) broke more than 1 day before delivery FORMCHECKBOX Other (specify): __________________________________Baby was born FORMCHECKBOX head first FORMCHECKBOX breech (feet first) FORMCHECKBOX vaginal FORMCHECKBOX Cesarean (Why? ________________ Birth weight lbs oz Length in. (if known) Head circumference ______ in. (if known) Apgar Scores (if known): ______ at 1 min ______ at 5 minNewborn period:Was the child healthy as a newborn? FORMCHECKBOX Yes FORMCHECKBOX No If not, please describe the problems and treatment:-28575-381000-285758699500Was the child born with any birth defects? FORMCHECKBOX Yes FORMCHECKBOX No If yes, explain: __________________________-2857524955500-2857523304500Did the child require treatment in a newborn intensive care unit? FORMCHECKBOX Yes (for _________ days) FORMCHECKBOX No Did the baby require any special care immediately after birth? FORMCHECKBOX Yes FORMCHECKBOX No If yes, √ all that apply FORMCHECKBOX Breathing problems (requiring FORMCHECKBOX oxygen FORMCHECKBOX ventilator (with a tube in windpipe) FORMCHECKBOX Placement in an incubator FORMCHECKBOX Blood transfusions FORMCHECKBOX Significant muscle weakness or paralysis FORMCHECKBOX Poor muscle tone FORMCHECKBOX Seizures FORMCHECKBOX Feeding difficulties FORMCHECKBOX Excessive sensitivity to noise/stimulation FORMCHECKBOX Jaundice treated with lights FORMCHECKBOX Infection FORMCHECKBOX Surgery (describe): __________________________________________________________________ Developmental HistorySocial DevelopmentDid you notice any delays in the client’s social development? FORMCHECKBOX Yes FORMCHECKBOX No As an infant, did the client:Enjoying cuddling? FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________Tend to be fussy/irritable? FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________Make appropriate eye contact? FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________Respond to his/her name? FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________In the first four years of life, were any special problems noted in the following areas? If yes, please describe below:Temper Tantrums FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________Separating from parents FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________Excessive crying FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________Playing with other children FORMCHECKBOX Yes FORMCHECKBOX No ________________________________________Speech and Language DevelopmentDid you notice any delays in the client’s language development? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please specify: __________________________________________________________________Did the following milestones develop on time? Please specify age (year/month).Show interest in sound (by 3 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Babbling (by 4 to 6 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Understanding words (by 6-11 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Speaking first words (by 12 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Speaking in short phrases (by 24 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Motor DevelopmentDid you notice any delays in the client’s motor development? FORMCHECKBOX Yes FORMCHECKBOX No If yes, please specify: ________________________________________________________________________Did the following milestones develop on time? Please specify age (year/month).Turn over (by 6 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Sit alone (by 9-12 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Crawl (by 9-12months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Stand alone (by 9-12 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Walk alone (by 12-18 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Walk upstairs (by 36 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Walk downstairs (by 48 months) FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Running FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Which hand does the client use for writing or drawing? FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX Both Eating? FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX Both Throwing? FORMCHECKBOX Right FORMCHECKBOX Left FORMCHECKBOX BothDaily LivingWhen was the client toilet trained?Days: _______________Nights:_______________Did bed-wetting occur after toilet training? FORMCHECKBOX Yes FORMCHECKBOX No If yes, until what age? _____________Did bed-soiling occur after toilet training? FORMCHECKBOX Yes FORMCHECKBOX No If yes, until what age? _____________Does your child have difficulty with sensory processing?If yes, please describe below:Tolerating Food Textures FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Gagging or Vomiting FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Tolerating Clothing FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Tolerating Touch from Others FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Does Not Notice Pain FORMCHECKBOX Yes FORMCHECKBOX No __________________________________Other ________________________________________________Significant LOSS of an acquired skill or skills (not just a delay)? For example, a child who was engaging in pretend play with other children for at least 4 to 6 months and then stopped and began just spinning, dropping, or throwing objects in his/her free time or speaking in full sentences for many months and then just stopped speaking altogether or began using only single words occasionally) Social functioning FORMCHECKBOX Age of loss: ______ months; Explain: _________________________________ ____________________________________________________________________Speech / language FORMCHECKBOX Age of loss: ______ months; Explain: _________________________________ ____________________________________________________________________Problem solving FORMCHECKBOX Age of loss: ______ months; Explain: _________________________________ ____________________________________________________________________Motor coordination FORMCHECKBOX Age of loss: ______ months; Explain: _________________________________ ____________________________________________________________________Bladder/bowel control FORMCHECKBOX Age of loss: ______ months; Explain: _________________________________ ____________________________________________________________________MEDICAL HISTORY FORMCHECKBOX No serious illnesses or injuries in the past FORMCHECKBOX No serious illnesses or injuries nowDateAgeDiagnosis/IllnessPastNowDateAgeDiagnosis/IllnessPastNowSerious Injuries FORMCHECKBOX FORMCHECKBOX Lung/breathing Problems FORMCHECKBOX FORMCHECKBOX Serious head injury FORMCHECKBOX FORMCHECKBOX Asthma FORMCHECKBOX FORMCHECKBOX Other serious injury FORMCHECKBOX FORMCHECKBOX Pneumonia FORMCHECKBOX FORMCHECKBOX Loss of consciousness FORMCHECKBOX FORMCHECKBOX Apnea or irregular breathing FORMCHECKBOX FORMCHECKBOX Sleep Problems FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Neurological Problems FORMCHECKBOX FORMCHECKBOX Stomach/bowel Problems FORMCHECKBOX FORMCHECKBOX Birth abnormality FORMCHECKBOX FORMCHECKBOX Swallowing problems FORMCHECKBOX FORMCHECKBOX Seizures (any type) FORMCHECKBOX FORMCHECKBOX Gastroesphageal reflux FORMCHECKBOX FORMCHECKBOX Other: _________________Chronic abdominal pain FORMCHECKBOX FORMCHECKBOX Vision Problem FORMCHECKBOX FORMCHECKBOX Chronic diarrhea FORMCHECKBOX FORMCHECKBOX Vision problems at birth FORMCHECKBOX FORMCHECKBOX Chronic constipation FORMCHECKBOX FORMCHECKBOX Requires glasses/contacts FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Kidney/Bladder Problems FORMCHECKBOX FORMCHECKBOX Hearing Problem FORMCHECKBOX FORMCHECKBOX Abnormalities at birth FORMCHECKBOX FORMCHECKBOX Hearing problems at birth FORMCHECKBOX FORMCHECKBOX Kidney/bladder infections FORMCHECKBOX FORMCHECKBOX Deafness FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Chronic ear infections FORMCHECKBOX FORMCHECKBOX Muscle/bone/joint) ProblemsEar tubes FORMCHECKBOX FORMCHECKBOX Abnormalities at birth FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Scoliosis or spinal curvature FORMCHECKBOX FORMCHECKBOX DateAgeDiagnosis/IllnessPastNowDateAgeDiagnosis/IllnessPastNowDental Problem FORMCHECKBOX FORMCHECKBOX Circulatory Problem FORMCHECKBOX FORMCHECKBOX Abnormally shaped/ missing teeth FORMCHECKBOX FORMCHECKBOX Anemia FORMCHECKBOX FORMCHECKBOX Extractions/cavities FORMCHECKBOX FORMCHECKBOX Sickle cell disease FORMCHECKBOX FORMCHECKBOX Dental braces FORMCHECKBOX FORMCHECKBOX Chronic low platelet count FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Bleeding /bruising problem FORMCHECKBOX FORMCHECKBOX Skin Problem FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Eczema FORMCHECKBOX FORMCHECKBOX Hormone Problem FORMCHECKBOX FORMCHECKBOX Ash leaf patches FORMCHECKBOX FORMCHECKBOX Sugar diabetes FORMCHECKBOX FORMCHECKBOX Café-au-lait spots FORMCHECKBOX FORMCHECKBOX Early puberty FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Late or incomplete puberty FORMCHECKBOX FORMCHECKBOX Growth Problem FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Failure to gain weight FORMCHECKBOX FORMCHECKBOX Mental Health problem FORMCHECKBOX FORMCHECKBOX Obesity FORMCHECKBOX FORMCHECKBOX ADHD FORMCHECKBOX FORMCHECKBOX Short stature FORMCHECKBOX FORMCHECKBOX Oppositional defiant disorder FORMCHECKBOX FORMCHECKBOX Tall stature FORMCHECKBOX FORMCHECKBOX Anxiety disorder FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Obsessive-compulsive disorder FORMCHECKBOX FORMCHECKBOX Heart Problem FORMCHECKBOX FORMCHECKBOX Depression FORMCHECKBOX FORMCHECKBOX Heart abnormalities at birth FORMCHECKBOX FORMCHECKBOX Bipolar disorder (manic-depressive) FORMCHECKBOX FORMCHECKBOX Heart surgery FORMCHECKBOX FORMCHECKBOX Schizophrenia FORMCHECKBOX FORMCHECKBOX Heart rhythm abnormalities FORMCHECKBOX FORMCHECKBOX Tic disorder (e.g., Tourette) FORMCHECKBOX FORMCHECKBOX High blood pressure FORMCHECKBOX FORMCHECKBOX Intellectual disability FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX Eating disorder (e.g., anorexia) FORMCHECKBOX FORMCHECKBOX Other: _________________ FORMCHECKBOX FORMCHECKBOX I have confirmed with my child’s Primary Care MD that his/her immunizations are up to date. FORMCHECKBOX Yes FORMCHECKBOX No If no, explain:_______________________________________________________________________Specialized neurological or genetic tests: FORMCHECKBOX No neurological or genetic testing has been done? If doneDate (if known)Month/YearTestNormalResultAbnormalResultUnknownResult FORMCHECKBOX EEG (brain wave test) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX CT scan FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX MRI scan FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX PET/SPECT/ scanroscopy FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other scan (specify): FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Chromosomal microarray FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Chromosomal analysis (karyotype) FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX DNA testing for fragile X syndrome FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Other genetic test: FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX List all hospitalizations and surgeries for the client, include overnight stays (medical or behavioral) FORMCHECKBOX No past hospitalizations or surgeryReason for hospitalization/surgeryAge Length of stayAllergies (to medications, foods, environmental antigens, etc.) FORMCHECKBOX No past or current allergiesSource (medication, food, etc.)Nature of reaction (hives, trouble breathing, etc.)Current Medications FORMCHECKBOX No medications taken now FORMCHECKBOX Medications are being taken now, but the names are not knownMedicationDosageAge at startReason for medicationImproved FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX N FORMCHECKBOX Y FORMCHECKBOX NName of person prescribing the medications: _________________________________________________RESOURCES: Please indicate resources/services being received now FORMCHECKBOX No resources/services are being received now FORMCHECKBOX Early Intervention Services (Agency:______________________________) FORMCHECKBOX Speech/Language therapy FORMCHECKBOX Psychiatry services FORMCHECKBOX Behavioral therapy FORMCHECKBOX Group therapy FORMCHECKBOX Physical therapy FORMCHECKBOX Occupational therapy FORMCHECKBOX Case management FORMCHECKBOX Wraparound services (WRAP) FORMCHECKBOX Mobile Therapist (MT) FORMCHECKBOX Behavior Specialist Consultant (BSC) FORMCHECKBOX Therapeutic Staff Support (TSS) FORMCHECKBOX Other: _______________________EDUCATIONAL HISTORY School name:_______________ Phone:Grade in school: (ever repeat a grade? Yes / No) Teacher (or best contact): ___________________ Is the client currently on a formal education plan in school? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please check: □ IEP □ 504 Plan What best describes the client’s current educational program?Full time in a regular class FORMCHECKBOX Time split between regular and special education classes FORMCHECKBOX Special education class FORMCHECKBOX Aide/Paraprofessional or extra help FORMCHECKBOX Specialized school FORMCHECKBOX Home schooled FORMCHECKBOX Please indicate the educational program in which the client participated during his/her school* years:School Year Type of SchoolRegular* Special Type of ClassRegular* Special* Any Special ServicesYes No Type3-5 preschoolKindergarten1st2nd 3rd4th5th6th7th8th9th10th11th12th * REGULAR school applies to public or private schools for children without disabilities. SPECIAL school applies to any schools intended for children with disabilitiesSOCIAL AND BEHAVIORAL FUNCTIONINGPeer RelationshipsPlease indicate how the client relates to peers: FORMCHECKBOX Has problems relating to other children FORMCHECKBOX Has difficulty making friends FORMCHECKBOX Fights frequently with peers FORMCHECKBOX Prefers playing with younger children FORMCHECKBOX Prefers playing with older children FORMCHECKBOX Prefers to play alone FORMCHECKBOX Has a best friendWhat role does the client take in peer groups? FORMCHECKBOX Leader FORMCHECKBOX Follower FORMCHECKBOX Some of EachHow many friends does the client have? _________________________Recreational InterestsWhat does the client enjoy? FORMCHECKBOX Sports _________________________________________________________________________________ FORMCHECKBOX Hobbies________________________________________________________________________________ FORMCHECKBOX Other _________________________________________________________________________________What are the client’s personal strengths?What do you enjoy most about the client?What are your hopes for the client’s future? ................
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