Child Development History

CHILD DEVELOPMENT HISTORY
Individual Information
Child's Name*

First NameMiddle InitialLast Name
Parent/Guardian Completing Form's Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Child's Current Age*
What are the problems that caused you to seek help for this child?
Family History
Who does the child live with?*

Both ParentsMotherFatherMother & StepfatherFather & StepmotherLegal GuardianOther
Status of parents' Marriage?*

MarriedSeparatedDivorcedWidowedSingle
How long married?
How long divorced?
Child's age at divorce?
Birth Mother
Current age   Date
Highest grade completed
Diploma/Degree
Occupation
Birth Father
Current age   Date
Highest grade completed
Diploma/Degree
Occupation
Please describe any special education or tutoring received by birth mother:
Please describe any special education or tutoring received by birth father:
Please described any grades repeated or subjects failed by birth mother:
Please described any grades repeated or subjects failed by birth father:
Please describe any learning difficulty, subject, and grade level at which it occurred for birth mother:
Please describe any learning difficulty, subject, and grade level at which it occurred for birth father:
Please describe any behavior problems and treatments received by birth mother:
Please describe any behavior problems and treatments received by birth father:
Please describe any psychological or psychiatric problems for which treatment was received by birth mother:
Please describe any psychological or psychiatric problems for which treatment was received by birth father:
Any attention or hyperactivity problems for birth mother? Describe any treatments:
Any attention or hyperactivity problems for birth father? Describe any treatments:
  Adoptive Mother
  Stepmother
Other  Please specify
Current age   Date
Highest grade completed
Occupation
  Adoptive Father
  Stepfather
Other  Please specify
Current age   Date
Highest grade completed
Occupation
Other Children (include step-siblings and half-siblings):
Biological Extended Family

Do any extended family members (maternal/paternal grandparents, uncles, aunts cousins) of the child suffer a problem with inattentiveness, hyperactivity, epilepsy, seizures, migraines, alcoholism, substance abuse; psychological, emotional, or personality difficulty; learning problems or developmental disabilities, and/or a “nervous” or neurological disorder; etc.? If yes, please list their relationship to you, the disorder, and any treatment received.
Maternal (mother's side)
Relationship, disorder & any treatment received.
Paternal (father's side)
Relationship, disorder & any treatment received.
Please note any other information about the child’s extended family that might help us understand the medical, developmental, behavioral, educational, emotional, or psychological growth.
Birth and Developmental History
Pregnancy
Length in months   Length of pregnancy
Any illnesses or complications during pregnancy?   Yes   No  If yes, please explain   Complications
Medications taken during pregnancy?   Medications
Substances used during pregnancy?
   Cigarettes       How many?   per day   per week
   Alcohol   How many?      per day   per week
   Drugs      Please describe type(s) of drugs, frequency of use, and at what month of pregnancy use was stopped (if applicable):   Types of drugs uesd, frequency of use, month of pregnancy use stopped (if applicable).
Was the father taking any medications or drugs at time of conceptions? If so what?   Father's medications and/or drug use.
How many pregnancies and/or miscarriages did the mother have?Number of pregnancies and/or miscarriages.

Labor and Delivery
Was the birth "normal" and uneventful?    Yes   No If no, please explain.

Perinatal History
Birth weight
Length
APGAR scores
Did the mother or child stay in Special or Intensive Care?   Yes  No   If yes, please describe
List any birth defects
Infancy and Childhood
Please rate childhood behaviors: Check 1 if the behavior on the left was present the majority of the time; Check 5 if the behavior on the right was present the majority of the time. Stages in between are represented by 2, 3, and 4.
quiet and content 1   2   3   4   5 colicky and irritable
very easy to feed   1   2   3   4   5 daily feeding problems
slept well   1   2   3   4   5 frequent sleeping problems
usually relaxed 1   2   3   4   5 often restless
under-active    1   2   3   4   5  over-active
easy to hold/cuddle 1   2   3   4   5  did not enjoy holding or cuddling
easy to calm down  1   2   3   4   5  tantrums and/or head-banging
cautious, careful  1   2   3   4   5  accident prone and/or daredevil
coordinated 1   2   3   4   5  uncoordinated
liked eye contact  1   2   3   4   5  avoided eye con   tact
enjoyed people  1   2   3   4   5   disliked contact with people
Other problems or comments regarding infancy or early childhood development:
Did any event, health condition, separation, etc., disturb early infant/mother bonding or the developing toddler/ mother relationship?   Yes   No  If yes, please explain:

Ages at Milestones
Gross motor: crawled @months, walked alone @ months, ran well @months
Fine motor: fed self with spoon @  months, scribbled @   months, tied shoes @  months
Language: used single words @months, used sentences (2+ words) months, described activity @ months months
Social/Adaptive: toilet trained/day @ months months, toilet trained/night @ months months
Rate of development overall: Slow   Normal   Fast
Medical History
Was the child ever taken to the emergency room with a serious emergency, hospitalized, or had an outpatient surgery since birth?

YesNo
If yes, please describe condition/injury, treatment, any surgery, when, how long, and where.
If the child had a head injury, did he/she lose consciousness?   Yes   No
If yes, how long?
Was he/she comatose?   Yes   No      If yes, how long?
Is the child seen as   hyperactive?   inattentive?   a behavior problem?
Would adults describe the child as able to control his/her behavior & attention?    Yes   No     If no, please explain
Describe any other handicapping conditions or special health considerations and their treatments.
Were hearing tests normal?   Yes   No      If no, please describe
Were vision tests normal?   Yes   No      If no, please describe
List any medications (including nonprescription medications) taken in the past and any the child is currently taking:
Overall, the child's health is:

PoorFairGoodExcellent
Behavioral and Mental Health History
Describe any behaviors that are concerning adults in the child’s life.
List any unusual, traumatic, or possibly stressful events in the child’s life that may have had an impact on development. Include incident, age at the time, and any comments.
Personality and Behavior
Check all traits that apply to the child:

SadHappyLeaderFollowerMoodyFriendlyQuietOveractiveIndependentDependantSensitiveAffectionateFearfulCooperativeTantrumsLethargicToo ResponsibleTrouble SleepingHard to DisciplineEasy GoingEven TemperedPrefers to be Alone
Educational History
Did the child attend preschool or daycare? If so, list location, type of program, number of days per week, age when started, and progress in program.
Describe child’s performance and any concerns in each grade:
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
Middle School
Any special education programs?   Yes   No      If yes, describe
Learning disability (LD):   Subjects
Language disorder:   Type
Tutoring:   Subjects
Any intelligence or achievement testing?   Yes   No       If yes, what were the results?
Should be Empty:

CHILD DEVELOPMENT HISTORY

Individual Information

Family History

Birth and Developmental History

Medical History

Behavioral and Mental Health History

Educational History