Children’s Developmental History Form Step 1 of 11 9% Child’s Name:* Birth date:* 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 StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 Pediatrician TelephoneIs this child currently on medication? No Yes Has this child ever had psychological/psychiatric counseling or therapy? No Yes If yes, indicate type and reason If yes, counselor’s name PhoneType of counselingWhen?Has this child ever had a neurological exam? No Yes If yes, neurologist’s name Date of exam? Day Month Year Reason for exam/findingsOther outside therapists/professionals/evaluations: Parents/Family Mother’s Name: Stepmother? No Yes Address 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? No Yes Address 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? No Yes Who 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? Yes No Other Services? Yes No Is the school aware that your child is being evaluated? Yes No School 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? No Yes Any problems in preschool? No Yes At what age? Amount of time per day If yes, describe: KindergartenDoes or did this child attend kindergarten? No Yes Any problems in kindergarten? No Yes If 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 progression No Yes If yes, when and why? Has been retained a grade in school No Yes If yes, when and why? Has skipped a grade in school No Yes If yes, when and why? Has difficulty with reading No Yes If yes, describe: Has difficulty with math No Yes If yes, describe: Gets poor grades No Yes Describe most recent report card results: Has been tested for special education No Yes If yes, when? Currently is placed in special education classes No Yes If yes, what type of class? Hours per day Dislikes going to school No Yes Is absent from school frequently No Yes If yes, why? If in high school, when will this child graduate? No Yes If yes, describe: Do you have any concerns about the quality of the child’s school or teachers? No Yes If yes, describe: Perinatal/Birth HistoryWas this child a planned pregnancy? No Yes Was this child adopted? No Yes Number 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: Reason What 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? Yes No If no, where? Length of pregnancy: Birth weight:lbsOz Length of labor: Apgar scoreslbsOz Child’s condition at birth Mother’s condition at birth Check 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? No Yes If yes, how long? Describe Supplemental oxygen? No Yes If yes, how long? Was anesthesia used during delivery? No Yes If yes, what kind? Length of stay in hospital (Mother): Child: DevelopmentAt what age did this child first do the following? Indicate age. Turn over Age Show interest in or attraction to sound Crawl Understand first words Speak first words Walk alone Speak in sentences Was this child breast-fed? No Yes When weaned? Was this child bottle-fed? No Yes When weaned? When was this child toilet trained?Days:Nights? Did bed-wetting occur after toilet training? No Yes If yes, until what age? Did bed-soiling occur after toilet training? No Yes If yes, until what age? Were there any medical reasons for bed-wetting or –soiling? No Yes If yes, please describe: Has this child experienced any of the following problems? If yes, please describe. Walking difficulty No Yes Unclear speech No Yes Feeding/eating problem No Yes Weight (under/over) No Yes Colic No Yes Sleep problem No Yes Difficulty learning to ride a bike No Yes Difficulty learning to skip No Yes Difficulty learning to throw or catch No Yes If 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 tantrums No Yes Separating from parents No Yes Excessive crying No Yes Which 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? No Yes Recurrent? No Yes Number, if known Hearing problems? No Yes Ear tubes No Yes Date of most recent hearing exam Vision problems No Yes Wears glasses or contacts No Yes Date 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: Describe Please describe other serious illnesses or operations:Illness/OperationAge Has this child ever been on long term-medication (more than 6 months)? No Yes No Yes If yes, when? What kind? Please indicate whether this child currently has any of the following problems.If yes, describe how often. Frequent colds No Yes Chronic cough No Yes Asthma No Yes Hay fever No Yes Sinus condition No Yes Shortness of breath or dizziness: No Yes With physical exertion No Yes Heart condition No Yes Heart murmur No Yes GI/Stomach difficulties No Yes Muscle pain No Yes When? Where? Clumsy walk No Yes Other muscle problems No Yes If yes, describe: Frequent rashes No Yes Bruises No Yes Sores No Yes If yes, describe: Severe acne No Yes Itchy skin (eczema) No Yes Seizures/convulsions No Yes If yes, describe: Speech Issues No Yes Accident prone No Yes Sucks thumb No Yes Grinds teeth No Yes Has tics/twitches No Yes Bangs head No Yes Rocks back and forth No Yes Bowel movements No Yes In pants/bed No Yes AllergiesSeasonal Allergies No Yes If yes, describe: Allergy to Food No Yes If yes, describe: Other Allergies No Yes If 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.Cancer Tay-Sachs disease Cystic fibrosis Tourette’s syndrome Diabetes Birth defect Heart disease Cerebral palsy High blood pressure Substance abuse Kidney disease Behavior disorder Migraine headaches Emotional disturbance Multiple sclerosis Mental illness Physical handicap Mental retardation Stroke Nervousness Tuberculosis Seizures or epilepsy Alzheimer’s disease Reading problem Hemophilia Other learning disability Huntington’s chorea Speech or language problem Muscular dystrophy Food allergies Parkinson’s disease Severe head injury Sickle-cell anemia Other: DescribeDescribe father’s present health.Describe mother’s present health.Has anyone in the family ever been in special education? No Yes If 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. No Yes If yes, describe. Frequent fights with playmates No Yes If yes, describe. Prefers playing with younger children No Yes If yes, describe. Has difficulty making friends No Yes If yes, describe. Prefers to play alone No Yes If yes, describe. Are there children in the neighborhood with whom this child could play? No Yes If 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? No Yes If yes, describe. Behavior/Temperament Please indicate whether this child exhibits any of the following behaviors.Is easily overstimulated in play No Yes Seems overly energetic in play No Yes Has a short attention span No Yes Seems impulsive No Yes Lacks self-control No Yes Overreacts when faced with a problem No Yes Seems unhappy most of the time No Yes Withholds affection No Yes Hides feelings No Yes Requires a lot of parental attention No Yes Seems Uncomfortable meeting new people No Yes Has fears No Yes If yes, describe What makes this child angry? Adaptive SkillsPlease indicate whether this child has the following skills.Dresses self No Yes Bathes self No Yes Helps with household chores No Yes Buys gifts or presents for others No Yes Has good table manners No Yes Says “please” and “thank you” No Yes Tells time accurately No Yes Knows how to get help or find home if lost No Yes Does this child receive an allowance? No Yes If yes, how does he/she spend it?Any other relevant information? Δ
