• Child / Adolescent History Form

    Child / Adolescent History Form

  • Patient Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Handedness
  • Primary Language(s)
  • Is the patient:

  • Prenatal / Birth History

  • Adequate prenatal care?
  • Complications during pregnancy? (e.g., substance use, maternal stress/trauma, physical injury)
  • Delivery method:

  • Delivery time:              weeks or months.

  • Complications with labor or delivery (e.g., NICU care)?

  • Developmental Milestones

  • Language:
  • Received speech/language therapy?
  • Motor:
  • Received physical/occupational therapy?
  • Toileting
  • Current toileting behavior:

  • Medical History

  • Immunizations

  • Please provide answers below for any relevant medical history, or leave blank if a section does not apply.

  • Neurodevelopmental / Psychological History

  • Intervention History

  • FAMILY

  • Current living situation:
  • Diagnoses in maternal extended family:
  • Diagnoses in paternal extended family:

  • Strengths / Social / Leisure

  • Social skills:
  • Is patient interested in friends?
  • Has the patient ever been interested in friends?

  • LEGAL

  • EDUCATION

  • Schooling type:
  • Did patient participate in any preschool or developmental program prior to kindergarten?
  • Has patient ever been retained / held back?
  • Has patient ever been suspended or expelled?
  • Does the patient have an Individualized Education Plan (IEP)?
  • Does the patient have a a Section 504 plan?

  • Other Information

  • This document is used to collect vital information in preparation for the parent interview. There may be greater detail or additional information that you would like to share and this will be discussed in-depth. You are welcome to provide additional documents during or before the visit. To make the most of the parent interview, please bring copies of (or send ahead of time) important documents such as previous evaluations, IEPs, medical records, etc.

  • Please visit our website for additional information that you may find useful to help prepare for the parent interview and the rest of the assessment process. https://hrapsychservices.com/pmc

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