Children’s Developmental History Form Step 1 of 11 9% Child’s Name:*Birth date:* Date Format: DD slash MM slash YYYY Age:School:Grade*Select GradePre-NurseryNursery SchoolPre - Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeHS GraduateNot ApplicableHeld Back?Select Held BackYesNoNot ApplicableAddress* Street Address City Enter StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance CarrierReferred By:Reason for Referral:What concerns do you have regarding your child and what questions were you hoping to answer from this evaluation?Current services / frequency (i.e. Counseling, Occupational Therapy, Physical Therapy, Speech Therapy, Special Education) Child’s PediatricianTelephoneIs this child currently on medication?NoYesHas this child ever had psychological/psychiatric counseling or therapy?NoYesIf yes, indicate type and reasonIf yes, counselor’s namePhoneType of counselingWhen?Has this child ever had a neurological exam?NoYesIf yes, neurologist’s nameDate of exam? DD MM YYYY Reason for exam/findingsOther outside therapists/professionals/evaluations: Parents/Family Mother’s Name:Stepmother?NoYesAddress Street Address Address Line 2 Home Phone:Work Phone:Cell Phone:E-mail Occupation:Employer:How long with present employer?Highest grade completed?Father’s Name:Stepfather?NoYesAddress If Different: Street Address Home Phone:Work Phone:Cell Phone:E-mail Occupation:Employer:How long with present employer?Highest grade completed?Names: Brothers/Sisters Please list all brothers and sisters, and any other children living with the family.Brothers and SistersAgeSexRelationship to this childSchool & grade Family RelationsHow does this child get along with brother(s) and/or sister(s)?In which activities does the family participate together with this child?What do you find most enjoyable about this child?What do you find most difficult about raising this child?Describe discipline techniques:Who is mainly in charge of discipline in the home? Child Care If primary caregivers work outside the home, please provide the following information:Does this child have other caretakers?NoYesWho cares for this child when caregivers are gone?How many hours per day is this child in a child-care setting?How many different people care for this child?Do all caregivers agree on discipline? Educational HistoryGradeSelect GradePre-NurseryNursery SchoolPre - Kindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeHS GraduateNot ApplicableSchool Currently Attending:Class Type/Size: Mainstream Inclusion self-contained Resource Room?YesNoOther Services?YesNoIs the school aware that your child is being evaluated?YesNoSchool Phone:Please list all schools attended since kindergarten and reason for transfer if applicable:School NameGrade(s) attendedYear(s) attendedReason for leaving PreschoolDoes or did this child attend preschool?NoYesAny problems in preschool?NoYesAt what age?Amount of time per dayIf yes, describe: KindergartenDoes or did this child attend kindergarten?NoYesAny problems in kindergarten?NoYesIf yes, describe Elementary/High School Please indicate whether this child has had any of the following school experiences.Has changed schools for any other reason than academic progressionNoYesIf yes, when and why?Has been retained a grade in schoolNoYesIf yes, when and why?Has skipped a grade in schoolNoYesIf yes, when and why?Has difficulty with readingNoYesIf yes, describe:Has difficulty with mathNoYesIf yes, describe:Gets poor gradesNoYesDescribe most recent report card results: Has been tested for special educationNoYesIf yes, when?Currently is placed in special education classesNoYesIf yes, what type of class?Hours per dayDislikes going to schoolNoYesIs absent from school frequentlyNoYesIf yes, why?If in high school, when will this child graduate?NoYesIf yes, describe:Do you have any concerns about the quality of the child’s school or teachers?NoYesIf yes, describe: Perinatal/Birth HistoryWas this child a planned pregnancy?NoYesWas this child adopted?NoYesNumber of previous pregnancies/miscarriages:Check any of the following complications that occurred during the pregnancy: Difficulty in conception Abnormal weight gain Measles Excessive vomiting German measles Flu Excessive swelling Emotional problems Anemia Vaginal Bleeding Other (Rh incompatibility, etc.) Hospitalization during pregnancy: Reason Injuries/accidents during pregnancy: Medications used during pregnancy: Alcohol used during pregnancy: ReasonWhat month?What kind?Frequency:Other drugs used during pregnancy:TypeFrequency Prescription Yes No Yes No Birth:At this child’s birth, what was the mother’s age?Father’s age?Was this child born in a hospital?YesNoIf no, where?Length of pregnancy:Birth weight:lbsOz Length of labor:Apgar scoreslbsOz Child’s condition at birthMother’s condition at birthCheck any of the following complications that occurred during birth. Forceps used Breech birth Labor induced Caesarean delivery Other delivery complications: Incubator: Jaundiced: Bilirubin lights? Breathing problems right after birth: DescribeHow long?Jaundiced: Bilirubin lights?NoYesIf yes, how long?DescribeSupplemental oxygen?NoYesIf yes, how long?Was anesthesia used during delivery?NoYesIf yes, what kind?Length of stay in hospital (Mother):Child: DevelopmentAt what age did this child first do the following? Indicate age. Turn over AgeShow interest in or attraction to soundCrawlUnderstand first wordsSpeak first wordsWalk aloneSpeak in sentencesWas this child breast-fed?NoYesWhen weaned?Was this child bottle-fed?NoYesWhen weaned?When was this child toilet trained?Days:Nights? Did bed-wetting occur after toilet training?NoYesIf yes, until what age?Did bed-soiling occur after toilet training?NoYesIf yes, until what age?Were there any medical reasons for bed-wetting or –soiling?NoYesIf yes, please describe: Has this child experienced any of the following problems? If yes, please describe. Walking difficultyNoYesUnclear speechNoYesFeeding/eating problemNoYesWeight (under/over)NoYesColicNoYesSleep problemNoYesDifficulty learning to ride a bikeNoYesDifficulty learning to skipNoYesDifficulty learning to throw or catchNoYesIf yes, please describe.During this child’s first 4 years, were there any special problems noted in the following areas? If yes, please describe.Temper tantrumsNoYesSeparating from parentsNoYesExcessive cryingNoYesWhich hand does this child use for writing or drawing?Eating?Other (throwing, etc.)?If dominant hand is left hand, are there any other immediate family members who are also left handed? Medical HistoryHearing and VisionEar infections?NoYesRecurrent?NoYesNumber, if knownHearing problems?NoYesEar tubesNoYesDate of most recent hearing examVision problemsNoYesWears glasses or contactsNoYesDate of most recent vision exam Childhood Illnesses/InjuriesPlease check the illnesses this child has had and indicate age (year/month). Measles Rheumatic Fever German Measles Diptheria Mumps Meningitis Chicken pox Encephalitis Tuberculosis Anemia Whooping Cough Fever above 104* Scarlet fever Head injury: DescribePlease describe other serious illnesses or operations:Illness/OperationAge Has this child ever been on long term-medication (more than 6 months)? No YesNoYesIf yes, when?What kind?Please indicate whether this child currently has any of the following problems.If yes, describe how often. Frequent coldsNoYesChronic coughNoYesAsthmaNoYesHay feverNoYesSinus conditionNoYesShortness of breath or dizziness:NoYesWith physical exertionNoYesHeart conditionNoYesHeart murmurNoYesGI/Stomach difficultiesNoYesMuscle painNoYesWhen?Where?Clumsy walkNoYesOther muscle problemsNoYesIf yes, describe:Frequent rashesNoYesBruisesNoYesSoresNoYesIf yes, describe:Severe acneNoYesItchy skin (eczema)NoYesSeizures/convulsionsNoYesIf yes, describe:Speech IssuesNoYesAccident proneNoYesSucks thumbNoYesGrinds teethNoYesHas tics/twitchesNoYesBangs headNoYesRocks back and forthNoYesBowel movementsNoYesIn pants/bedNoYes AllergiesSeasonal AllergiesNoYesIf yes, describe:Allergy to FoodNoYesIf yes, describe:Other AllergiesNoYesIf yes, describe Family Health Have any family members had any of the following? If yes, please specify family member’s relationship to this child. If child is not living with biological parents, please include health information on biological parents, if known.CancerTay-Sachs diseaseCystic fibrosisTourette’s syndromeDiabetesBirth defectHeart diseaseCerebral palsyHigh blood pressureSubstance abuseKidney diseaseBehavior disorderMigraine headachesEmotional disturbanceMultiple sclerosisMental illnessPhysical handicapMental retardationStrokeNervousnessTuberculosisSeizures or epilepsyAlzheimer’s diseaseReading problemHemophiliaOther learning disabilityHuntington’s choreaSpeech or language problemMuscular dystrophyFood allergiesParkinson’s diseaseSevere head injurySickle-cell anemiaOther: DescribeDescribe father’s present health.Describe mother’s present health.Has anyone in the family ever been in special education?NoYesIf yes, who?What type of class? Social-Emotional Functioning Please indicate how this child relates to other children. Has problems relating to or playing with other children.NoYesIf yes, describe.Frequent fights with playmatesNoYesIf yes, describe.Prefers playing with younger childrenNoYesIf yes, describe.Has difficulty making friendsNoYesIf yes, describe.Prefers to play aloneNoYesIf yes, describe.Are there children in the neighborhood with whom this child could play?NoYesIf yes, describe.What roles does this child take in peer group games (for example, leader, aggressor, etc.?) Recreation/InterestsWhat activities does this child enjoy?Sports:Hobbies:Others Has this child’s interest in participating in these activities declined recently?NoYesIf yes, describe. Behavior/Temperament Please indicate whether this child exhibits any of the following behaviors.Is easily overstimulated in playNoYesSeems overly energetic in playNoYesHas a short attention spanNoYesSeems impulsiveNoYesLacks self-controlNoYesOverreacts when faced with a problemNoYesSeems unhappy most of the timeNoYesWithholds affectionNoYesHides feelingsNoYesRequires a lot of parental attentionNoYesSeems Uncomfortable meeting new peopleNoYesHas fearsNoYesIf yes, describeWhat makes this child angry? Adaptive SkillsPlease indicate whether this child has the following skills.Dresses selfNoYesBathes selfNoYesHelps with household choresNoYesBuys gifts or presents for othersNoYesHas good table mannersNoYesSays “please” and “thank you”NoYesTells time accuratelyNoYesKnows how to get help or find home if lostNoYesDoes this child receive an allowance?NoYesIf yes, how does he/she spend it?Any other relevant information?