CLIENT'S PARENT 1:
CLIENT'S PARENT 2:
CLIENT'S SIBLINGS AND/OR OTHERS WHO LIVE IN THE HOUSEHOLD
FAMILY HEALTH HISTORY
Child number of total children.
Length of hospitalization: Mother: blanks Baby: blank
Developmental History. Please note the age at which the following behaviors took placeSat Alone: blanks Dressed Self: Took 1st Steps: Spoke Words: Fed Self: Tied Shoelaces: Rode Two-Wheeled Bike: Dry During Day: Dry During Night
Check the descriptions that specifically relate to the child.
Who handles responsibility for your childing in the following areas?
If the child is involved in a vocational program or works a job, please fill out the following:
Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, curch activities, walking, exercising, diet/health, hunting, fishing, bowling, school, scouts, etc.)
Most Recent Examinations
Physical Exam: Date Results: Dental Exam: Date Results: Vision Exam: Date Results: Hearing Exam: Date Results:
Current Prescribed Medications: Type: Doses: Dates: Date Purpose: Side Effects:
Type: Doses: Dates: Date Purpose: Side Effects:
Current Over the Counter Medications: Type: Doses: Dates: Date Purpose: Side Effects:
COUNSELING/PRIOR TREATMENT HISTORY