Developmental History

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Which Sprout Therapist Should See this?
Please check all that apply to your pregnancy and prenatal exerience
Pregnancy

Difficulty getting pregnant or one or more miscarriagesComplications during pregnancyFertility drug useFlu or other infectionGestational diabetesOther
Please Check all that apply to your delivery
Prenatal

Age 35 or olderOverweight or obeseAutoimmune diseaseHistory of allergies and immune deficiencies, chronic fatigue, or fibromyalgiaThyroid dysfunctionPossible exposure to toxic chemicals or pesticidesOther
Please check all that apply to your experience
Birth

Breech presentationCesarean sectionForceps deliveryOxygen deprivationBruising or swelling about the head and neckInduce laborOther
Was your child born premature? If so, how many weeks?
Has your child ever been diagnosed with Torticollis?
Does your child have seizures?
Does your child have a shunt?
Milestones
Please check milestones your child achieved during this time frame
If diagnosed with Torticollis, please specify which side
Birth to Age One

Colic and other digestive problemsAlternate chronic constipation and diarrheaSpitting up (reflux) or projectile vomitingPyloric stenosis (stomach obstruction)Allergies and/or AsthmaThrush (yeast infection)Eczema at birth that got worseChronic ear infections that were aggressively treated with antibioticsReactions to immunizationsSleep disturbancesHypotonia (low muscle tone)Possible sensory deprivationOther
By the end of the first month most babies:

make jerky quivering arm movementsbring hands near facekeep hands in tight fistsmove head side to side while laying on stomachfocus on objects 8-12 inches awayprefer human faces over other shapesprefer black and white or high contrast patternshear very wellrecognize some sounds including parents voices
By the end of their third month most babies:

Raise head and chest when lying on stomachsupport upper body with arms when lying on stomachstretch legs out and kick when lying on stomach or backpush down on legs when feet are placed on a firm surfaceopen and shut handsbring hands to mouthgrab and shake hand toysfollow moving objects with eyeswatch faces closelyrecognize familiar objects and people from a distancestart using hands and eyes in coordinationbegin to babble and imitate some soundssmile at the sound of parents voicesenjoy playing with other peoplemay cry when playing stops
By the end of their seventh month most babies:

roll over both ways (stomach to back, back to stomach)sit upreach for object with handtransfer objects from one hand to the othersupport whole weight on legs when held uprightdevelop full color vision and mature distant visionuse voice to express jay and displeasurerespond to own namebabble chains of consonants (ba ba ba)distinguish emotion by tone of voiceexplore objects with hands and mouthstruggle to get objects that are out of reachenjoy playing peek a booshow an interest in mirror imagescrawl
By Their First Birthday, Most Babies:

Sit without assistanceGet into hands and knees positionpull self up to standwalk holding on to furniture and possibly a few steps without supportuse pincer grasp with the thumb and forefingersay dada and mamause exclamations such as uh oh!try to imitate wordsrespond to no and simple verbal requestsuse simple gestures such as shaking head no and waving bye byeexplore objects in many ways (shaking, banging, throwing and dropping)begin to use objects correctly (drinking from a cup and brushing hair)find hidden objects easilylook at correct picture when an image is named
Ages One to Two

Allergic symptoms: constant runny nose, red ears, puffy eyesWhite bumps on skinIncreasing hyperactivityStrabismus (lazy eye), possibly nystagmus (involuntary shaking of the eyes side to side)Regression in milestones around age twoOther
By Their Second Birthday, Most Children:

Walk on their ownPull toys behind them while walkingCarry large toy or several toys while walkingBegin to runKick a ballClimb on and off furniture without helpwalk up and down stairs while holding on to supportscribble with a crayonbuild tower of 4 blocks or morerecognize names of familiar people, objects or body partssay several single words (by 15-18 months)use simple phrases (by 18-24 months)use 2-4 word sentences (want snack)follow simple instructionsbegin to sort objects by shape and colorbegin to play make believeimitate behavior of othersshow growing independence
Ages Two to Three

Delayed or abnormal crawling, or skipped stages of crawling before walkingClumsy or floppy movementsTo-in foot or knock-kneedLisp in speechOther
Child's Diet

Increasingly limited diet due to strong likes and dislikesPreference for foods containing wheat and dairyPreference for milk and cereal or a bagel with cream cheese for breakfastPreference for grilled cheese sandwiches for lunchPreference for pizza pasta for dinner or secondarily chicken nuggetsSnacks on raw carrotsLoves eating French FriesOther
Does the Mother or Father Have any of the following Mental Health issues:

ADD/ADHDAnxietyDepressionOther
Portions of this developmental history were taken from information presented in Disconnected Kids By Dr. Robert Melillo
Please Keep a two week journal of what your child eats for breakfast, lunch, supper and snacks. Please include drinks and how many ounces he/she drinks.

If your child has allergies or food intolerances, please indicate this in the journal. Evaluator will need this brought to the eval or scanned and emailed to her to include in the report.
Once you have completed this form and pressed the submit button, someone from our office will be in touch to set up the consultation appointment. The fee for this appointment is $250. This fee will be reimbursed if you participate in a Sprout Academy program.
With regards to your child's daily activites, please rate on a scale of 1-10 the occurence of these statements
Balance Concerns:

The vestibular system is all about balance and spatial awareness. Please rank the following statements on a scale of 1 to 10 (one indicates "does not apply" ten indicates "almost always applies").