Child Information and Developmental History

Your present marriage/relationship

Your present work situation

Your present living circumstances

Home Setting History

Residential Placements, Institutions or Foster Care

Has your child had any learning problems? If yes, please describe.
Has your child had any social problems in school? If yes, please describe.
Is your child receiving special help at school? If yes, please describe.
Any other school related concerns?
What are your concerns about your child?
How long has this difficulty existed?
YesNo
If yes, where and when?
Do you have any ideas about why your child is having problems now?
Please list and describe your child's current symptoms. Please note when each symptom began.

Child's Health
List all severe illnesses, accidents, operations, handicaps and repeated medical problems (such as ear infections, headaches, etc.) and all other medical conditions. Please include the child's age, who they were treated by and any consequences.
List all medications, past and present. Please include the date that the medication was first prescribed, the name of the prescriber and the effect of the medication.
Pediatrician

First NameLast Name
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pediatrician's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Last Physical Exam

MonthDayYear
Date
Results of Last Physical Exam

At what age did the child do each of these? Were any of them difficult or slow to develop?

Rows	Age	Describe
Sat without support
Crawled
Walked without holding on
Helped when being dressed
Ate with a fork
Stayed dry all day? All night?
Didn't soil pants
Dressed self completely
Age said first word
Age said first sentences
Any speech, hearing, or other impediments/delays?
Writing
Reading
Riding a bicyle
Tying shoes

Indicate yes or no. If yes, please describe.

Rows	Yes	No	Describe
Is your child overactive?
Does your child have trouble paying attention?
Does your child have trouble staying with an activity?
Does your child have fluctuating moods?
Does your child get frustrated easily?
Are your child's emotional responses generally unpredictable?
Does it take your child a long time to warm up to new situations/people?
Does your child react strongly to physical pain?
Does your child react strongly to other things?

Have there been challenges in the following areas?

Has anyone in the family had any of the following? If so, specify relationship to the child.

Rows	Yes	No	Relationship	Describe
Neurological disease (seizures, etc.)
Medical disease (ex. diabetes, thyroid, heart disease)
Emotional conditions
Cognitive or physical delays
Learning problems
Behavior problems
Excessive use of alcohol
Excessive use of drugs
Trouble with the law
Trouble holding a job
Physical abuse
Sexual abuse
Other

Indicate yes or no. If yes, please explain.

Rows	Yes	No	Explain
Parental separation or divorce
Family moves
Recent deaths or losses (within last 3 years)
Other major family changes
Has anyone in your family seen a psychologist, psychiatrist, or other mental health care work?
Any recent changes/stresses in living situation or family?

Rate your satisfaction

Summary
Please describe your child's strengths:
What are your child's special skills or talents? List hobbies, sports, recreational, TV, toy preferences, etc.
Please feel free to write anything else about your child.
This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.
Should be Empty: