Developmental History Form

Developmental History Form

Welcome to Wise Mind Psychology Clinic. We want to make the most of every appointment you have with us. To begin, please fill out the following form as completely as possible. If you have questions about anything in this form, please feel free to ask your clinician for clarification. Please also feel free to provide any additional comments.
Name

First NameLast Name
Birth Date

DayMonthYear
Date
Email
example@example.com
Phone Number
Education completed (please list the highest grade completed and any post-secondary qualifications):
GP Details (name of GP, name of practice, address and phone number)
Lifestyle Factors
Smoking: Please select the option that applies regarding your smoking habits

None0 -1 packet a day1 - 2 packet a day2+ packet a day
Alcohol: Average number of alcoholic drinks per week?
Sleep: Average hour of sleep per night?
Exercise: Average number of times you exercise per week?
Current Health and Reason for Seeking Assessment
Please list any current health problems you may have
Please also list any serious illnesses, surgeries, or hospital stays you have had. How old were you when you had this/these?
What is your main reason for seeking an assessment?
How long has this been going on?
Why have you chosen to seek help now?
Have you had any previous assessments for these difficulties? If so, when? What was the main finding?
If you have any relevant reports, such as a previous cognitive assessment, please provide these to your clinician.
Psychiatric / Mental Health History
Have you been diagnosed with a psychiatric or mental health condition?
Have you been hospitalised for a psychiatric condition? If so, please elaborate.
Do you currently see a therapist or psychiatrist? If yes, please provide their details.
Have you previously seen a therapist or psychiatrist? If so, when?
Employment
What is your current job or occupation:
Are you having any trouble on the job? What are the parts that are most difficult for you?
Education History
When you were growing up, did you?:

like schoolnot like schoolfeel indifferent towards schoolOther
For each of the following, please indicate generally how you did academically. Please also describe any special help you received (resource, guidance, accommodations, etc.)
I. Early primary school (Grades Prep-3)
II. Late primary school (Grades 4-6)
III. Early High School Years (Years 7-9)
IV. Final High School Years (Years 10-12)
What was your best subject at school?
What was your worst subject?
Reading
Did you have any problems with reading? (Please check any that apply):

late learning to readsounding wordsreading aloudreading comprehensionmemory of material read
Other comments about your reading:
Writing
Did you have problems with writing?

spellinggrammarneatness of handwritingcreativity (making up stories, etc.)organisation of ideas
Other commnets about your written expression:
Mathematics
In your maths work, did you have any significant problems with:

understanding new conceptsremembering “math facts”timed testscareless errors
Other comments about your maths work:
Did your teachers think you did as well as you could have done?

performed below potentialworked to potentialexceeded expectations
Speech and Memory
Did you have speech problems? If yes, please describe.
Did you receive speech and language therapy?

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

yesno
Were you in any type of special education program? If so, please describe.
Were you ever held back in a grade? If so, which one(s)?
Did teachers say that you were (please check any that apply):

DistractibleInattentiveDaydreamyHad difficulty listeningSlow movingSlow to respondImpulsiveHyperactiveSomeone who talked too muchSomeone who disturbed others in classOften out of your seat without permissionA class clownDisorganisedDifficulties with time managementDifficulties completing workUnmotivated or "lazy"Difficulty following instructionsDifficulty in thinking of what to sayUnder performing in school
School Social Life:
Did you have social problems as a child or teen? If so, please describe. (E.g., were you very shy around peers, aggressive, ignored or bullied?)
Did you have significant behavior problems? If so, please describe these as best you can.
Were you ever in fights at school? If so, approximately how many, and during which year levels?
Were you ever suspended or expelled from school?
Family Relationships
If you have a partner or spouse, how long have you been together?
What does he or she think about the difficulties you have been describing?
Do the problems affect your relationship? If so, how?
If you have children, do they seem to have any of the same problems you have been describing? Do any of your children have additional learning needs?
Your Family of Origin
Number of sisters:
Sisters' ages:
Number of brothers:
Brothers' ages:
Please indicate whether any of your siblings were not biologically related to you, or were half-siblings to you:
Did any of your siblings have difficulties similar to the ones with which you are struggling? If yes, please describe.
Your Parent / Caregiver 1.
Is she/he living?
If alive, their age:
If deceased, what was their age when he/she died and how old were you at this time?
Highest level of education he/she earned:
Their occupation:
Is this your biological parent?

yesno
Did she/he have difficulties similar to the ones with which you are struggling? If yes, please describe:
Your Parent / Caregiver 2.
If alive, their age:
If deceased, what was their age when he/she died and how old were you at this time?
Level of education he/she earned:
Their occupation
Is this your biological parent?

yesno
Did he/she have difficulties similar to the one(s) with which you are struggling? If yes, please describe:
Has any member of your extended family – parents, siblings, aunts, uncles, cousins, grandparents? (Please check any that apply):

Had trouble with paying attentionStruggled with hyperactivity or impulsivityWith serious behavior problemsExperienced serious school difficultiesSeemed much smarter than his or her achievement would indicateHad serious trouble with readingHad trouble with anxietyHad trouble with depressionSuffered fro another mental illnessHad trouble with drugsHad trouble with alcoholHad serious problems with the law
Please provide any additional comments if required:
Vision and Hearing
Have you ever had hearing difficulties?

YesNo
If so, have you ever used a hearing aid? And do you wear a hearing aid now?
Have you ever had difficulties with vision?

YesNo
Have glasses been prescribed?

YesNo
Early Childhood and Development
As far as you know, did your mother have any difficulties during her pregnancy with you?

YesNo
As far as you know, were there any difficulties or complications during your birth?

YesNo
Please provide any comments if necessary:
As far as you know, did you reach your physical developmental milestones (e.g. sitting up, crawling, walking, using a spoon): early, at the expected ages, or late?
As far as you know, did you reach verbal milestones (speaking single words, making short sentences, developing longer sentences): early, at the expected age, or late?
Is there anything else that you would like us to know?
Date

MonthDayYear
Date
Should be Empty: