Spectrumbehavioralhealthny.com-Childhood History

SPECTRUM BEHAVIORAL HEALTH

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Childhood History
Child's Name*

First Name Last Name
Child's Date of Birth*

MonthDay Year
Age
Sex:*
Home Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Home Phone #*

Area Code Phone Number
School Name*
School Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Child's Grade*
Special Placement (If any):*
Child is presently living with:*

Foster FatherOtherNatural MotherNatural FatherStep MotherStep FatherAdoptive MotherAdoptive FatherFoster Mother
If Others, Please specify:
Non-Residential adults involved with this child on regular basis:
Source of Referral Name
Referral Phone Number

Area Code Phone Number
Referral Address

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code
Briefly State Main Problems of this child:*

Parents

Mother
Mother's Name

First Name Last Name
Age
Occupation
Work Phone

Area Code Phone Number
Age at time of pregnancy with patient
Education (Highest grade completed)
Any Learning Problems (describe)
Any Attention Problems (describe)*
Any Behavior Problems (describe)*
Any Medical Problems (describe)
Mother or any of her blood relatives experienced problems similar to those your child is experiencing? If so, describe:
Father
Father's Name

First Name Last Name
Age
Occupation
Work Phone

Area Code Phone Number
Education (Highest grade completed)
Any Learning Problems (describe)
Any Attention Problems (describe)
Any Behavior Problems (describe)
Any Medical Problems (describe)
Have any of blood relatives of the child experienced problems similar to those your child is experiencing? If so, describe:*
Siblings
Please write the Name, Age and if there are any Medical/Social/School/Mental Health Problems for the siblings:

Name Age if there are any Medical/Social/School/Mental Health Problems
1
2
3
4
5
Pregnancy
Duration of Pregnancy
Complications:

Excessive VomittingExcessive Staining/Blood lossThreatened MiscarriageToxemia
Hospitalization required (specify)
Infection(s) (specify):
Operation(s) (specify):
Other Illness (specify)
Smoking during pregnancy (# of cigarettes/day)
Describe if more than occasional use of alcohol consumption during pregnancy
Medications taken during pregnancy
X-ray studies during pregnancy

	Early	Normal	Late
Smiled
Sat without support
Crawled
Stood without support
Walked without assistance
Spoke first words
Said phrases
Said sentences
Bladder trained, day
Bladder trained, night
Bowel trained, day
Bowel trained, night
Rode tricycle
Rode bicycle (without training wheels)
Buttoned clothing
Tied Shoelaces
Named colors
Named coin
Said alphabet in order
Began to read

	Yes	No
Doesn't sit still in his/her seat:
Frequently gets up and walks around the classroom:
Shouts out. Doesn't wait to be called on:
Won't wait for his/her turn:
Doesn't cooperate well in group activities:
Typically does better in one to one relationship:
Doesn't respect the rights of others:
Doesn't pay attention during storytelling or show and tell:

	Yes	No
Fidgets with hands, feet or squirms in seat
Has difficulty remaining seated when required to do so
Easily distracted by extraneous stimulations
Has difficulty awaiting turn in games or group situations
Blurts out answers to questions before they have been completed
Has problems following through with instructions (usually not due to opposition or failure to comprehend)
Has difficulty paying attention during tasks or play activities
Shifts from one uncompleted activity to another
Has difficulty playing quietly
Often talks excessively
Interrupts or intrudes on others (often not purposeful or planned but impulsive)
Does not appear to listen to what is being said
Loses things necessary for tasks or activities at home
Boundless energy and poor judgment
Impulsivity (Poor self control)
Frustrates easily
History of temper tantrums
Temper outbursts
Sloppy table manners
Sudden outbursts of physical abuse of other children
Acts like motor drives him/her
Wears out shoes more frequently than siblings
Excessive number of accidents
Doesn't seem to learn from experiences
Poor memory
A "different child"

	Name	Age	if there are any Medical/Social/School/Mental Health Problems
1
2
3
4
5