Developmental History Form

Developmental History Form
Today's Date:

MonthDayYear
Date
Legal Name

LastFirst, Middle
Name you go by:

LastFirst
Pronouns
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home phone
Cell phone
Email
example@example.com
Age
Birthday: (DD/MM/YYYY)
Sex assigned at birth
Gender
Sexual Orientation
Occupation
Highest level of education you have completed:
Birthplace
Is English your primary language?

YesNo
What other language (s) do you speak?
Reason for Evaluation
What is your main reason for seeking an evaluation?
Who referred you?
How long has this been going on?
Why have you chosen to seek help now?
Have you had any previous evaluations or assessments for these difficulties?
If so, when?
What were the main findings /diagnoses?
Do you have the report?

YesNo
Work and Education
Please describe the work you are currently doing. If you are not currently working, please describe your most recent employment (if applicable)
What parts of your job do you find the most difficult?
How is your job affected by your current difficulties?
Are you currently in school?

YesNo
If you are currently in school, where do you go?
Are you in full-time or part-time studies? How are your grades? How hard do you feel you had to work at your studies?
Did/Do you:

Like schoolNot like schoolFeel indifferent toward school
What was your best subject?
What was your worst subject?
Did you receive any special education services (IEP, 504 accommodations, etc.)?
Did you have any of the following difficulties with reading?

Late learning to readSounding wordsreading aloudmemory of material readreading comprehension
Other information about your reading:
Did you have any of the following difficulties with writing?

spellingneatness of handwritingorganization of ideasgrammarcreativity (making up stories, etc.)
Other information about your written expression:
Did you have any of the following difficulties with math?

understanding new conceptsremembering "math facts"timed testscareless errors
Other information about your math work:

How did you perform in the following subjects (if applicable):

	Below Average	Average	Above Average
Science
History
Music
Art
PE/Gym

In general, your teachers would say your performance was/is:

performing below potentialworking to potentialexceeding expectations
Did you have speech problems?

YesNo
If yes, describe:
Did you receive speech and language therapy?

YesNo
Were you thought to have memory problems of any kind?

YesNo
Were you ever retained or held back a grade?

YesNo
If so which one (s)?
Social
Did you have social problems as a child or teen?

YesNo
If so, please say more. For example, were you very shy around peers, aggressive, ignored, bullied, awkward, etc.?

As a child, how well did you:

	Below Average	Average	Above Average
Get along with siblings
Get along with peers
Make friends
Keep relationships

Has this changed over time? How so?
Were there any significant behavior problems growing up?

YesNo
Please describe these as best you can:
Were you ever in fights at school?

YesNo
Were you ever expelled or suspended from school?

YesNo
(If so, please explain)
Current Family System
Status:

singlemarrieddatingseparatedco-habitating
Please list the people you are living with; spouse, children, relatives, roommates, partner(s)
  Name    Relationship to you   Age     Gender
Occupation or grade   Health problems

Name   Relationship to you   Age   Gender   Occupation or grade   Health problems

Name    Relationship to you   Age     Gender
Occupation or grade   Health problems

Name   Relationship to you   Age   Gender   Occupation or grade   Health problems

Name   Relationship to you   Age   Gender   Occupation or grade   Health problems
How do people in your support system describe the difficulties you're experiencing?
During the past two years have you experienced any significant family events? (i.e., divorce, financial hardship, legal concerns, serious illness/death, substance use, family conflict)
Family of Origin
What was your family situation like when you were growing up? How were emotions discussed? Were you generally a happy or unhappy child?
Were you adopted?

YesNo
Only child?

YesNo
Parent/Guardian/caregiver 1:
Name Age Deceased? Yes No If so, when? How old were you? Is this a biological parent? Yes No Is this a biological parent? Highest level of education earned ? Current occupation
Please describe any mental health difficulties:
Parent/Guardian/Caregiver 2:
Name Age Deceased? Yes No If so, when? How old were you? Is this a biological parent? Yes No Highest level of education earned ? Current occupation
Please describe any mental health difficulties:
number of biological sisters Ages
number of biological brothers Ages
Do any of your siblings have mental health concerns? If so, please indicate who and the nature of the difficulties:
Do any members of your extended family (i.e., aunts, uncles, cousins, grandparents, etc.) have mental health concerns? If so, please indicate who and the nature of the difficulties
Health
How is your physical health generally?
Do you have a Primary Care Doctor?

YesNo
Name:
Date of last exam?

MonthDayYear
Date
Are you currently taking any medications regularly?
If so, please indicate the following:
Type and dosage
Purpose/Diagnosis
Prescriber:
If applicable, how are you doing on these medications?
Do you take any supplements, vitamins or over the counter medications regularly?
Have you been on any psychiatric medications in the past?
If so, please indicate the following:
Type and dosage:
Purpose/Diagnosis
Prescriber:
Have you ever been in counseling or psychotherapy"

YesNo
If so, when?
Was this helpful?

YesNo
Why or why not?
What were the main findings/diagnoses?
Would speaking to the above provider(s) be helpful?

YesNo
Please list any psychiatric hospitalizations, residential placements, or higher levels of care due to mental health concerns, including year and length of stay:
Have you ever had hearing difficulties?

YesNo
If so, have you ever used a hearing aid?

YesNo
Have you ever had difficulties with vision?

YesNo
Do you wear glasses?

yesNo
Do you wear contacts?

YesNo
Are any of the following problems for you? Please check all that apply.

HeadachesBack painOther chronic aches/painRapid heartbeatDizziness/lightheadednessUpset stomachMental confusion
As far as you know, did your mother have any difficulties during her pregnancy with you?

YesNo
As far as you know, during pregnancy, did your mother

Take prescription medicationSmoke cigarettesDrink alcoholuse street drugsuse caffeine
If yes, please elaborate:
Were there any difficulties with the delivery?

YesNo
As far as you know, when did you reach physical development milestones (sitting up, crawling, walking, using a spoon, etc.,)

EarlyAt the expected ageLate
As far as you know, when did you reach verbal milestones (speaking single words, making short sentences, developing longer sentences? Early, aecpected age. t the

EarlyAt expected ageLate
Have you ever had:

allergiesheart problemsblood pressure problemsthyroid difficultiesdiabetesconvulsions or seizuresHead injurymeningitisencephalitisticsother diseases or illnessunusual physical symptimsOther
Please list any serious illness, surgeries, or hospital stays you have had for medical reasons, and the year in which you had them.
How old were you when you had these? Are any effects of the condition still present?
Substance Use
Do you use caffeine?

YesNo
How many cups of the following on a typical day? Coffee, Tea, Cola.
Do you use nicotine?

YesNo
How many? cigarettes/vape tobacco
frequency
Do you use alcohol?

yesNo
If yes, on average, how often do you have beer, wine, or other alcohol?

daily4-6 times per week2-3 times per weekabout once a week2-3 times a monthabout once a monthless than once a month
Do you use cannabis (marijuana)?

YesNo

If so, on average, how often do you use cannabis?

	Daily	4-6 times per week	2-3 times a week	about once a week	2-3 times a month	about once a month	less than once a month
cannabis

If you use, or have used any street drugs (cocaine, amphetamines), when and how often?
Sleep
On average, how many hours of sleep do you get per night?
How long does it take before you fall asleep?
Is falling asleep difficult?

YesNo
Please provide some detail:
After you fall asleep, do you usually stay asleep all night?

YesNo
If not, about how many times do you wake up each night?
Do you have trouble getting back to sleep?

YesNo
Is it normally difficult for you to wake up and get moving in the morning?

YesNoAre you often tired during the day?YesNoDo you nap during the day?YesNo
How often are you late for school or work?
Nutrition and Exercise
How would you describe your appetite?
Does your mood affect your appetite?

YesNo
Please explain:
Has your weight significantly changed recently?
significant increasesignificant decrease
currently, are you trying to gain or lose weight?

YesNoHave you ever had an eating disorder?YesNo
Please say more about this:
How would you describe your typical energy level?
What kind of regular exercise do you do?
Mood: What is your usual mood?

even and stablesad, blueangry or irritableworried or anxiousOther
Please say more about this:
Are you currently distressed by any of the following?

work stressschool stressfinancial stresslegal stressdisturbing thoughtssocial fearsfamily problemsanger problemshealth problems
Please explain:
How would you describe your attention?
How would you describe your concentration?
Is there anything else not asked that you feel is important for us to know?
Should be Empty:

Developmental History Form

Reason for Evaluation

Work and Education

Social

Current Family System

Family of Origin

Health

Substance Use

Sleep

Nutrition and Exercise