Family History Questionnaire
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  • Family History Questionnaire

  • Today Date:
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  • Rows

  • *Please provide therapist copy of custody/visitation documentation.

  • Is child presently in any childcare setting?

  • Family History Questionnaire

    Page 2
  • Has your child ever been hurt?
  • If yes, check all that apply:
  • Do you have concerns about trauma or grief / loss?

  • DEVELOPMENTAL HISTORY

  • Were there any problems in pregnancy, labor, birth, or delivery with this child?

  • Have there been any concerns or delays with your development in any of the following areas?

    If yes, please indicate who evaluated the problem if help was sought:

  • 1. Speech and language
  • 2. Hearing
  • 3. Vision
  • 4. Intelligence / ability to learn:
  • 5. Bladder / Bowl control:
  • 6. Emotional / Maturity level:
  • 7. Social skills:
  • 8. Eating habits:
  • 9. Fine motor skills (writing, coloring. etc.):
  • 10. Gross motor skills (walking, running, etc.):

  • Family History Questionnaire

    Page 3

  • PREVIOUS TREATMENT

  • Rows
  • Does your child or another child in your family receive any other services at Therapy Associates? (please check all that apply)
  • If yes, Current or Past?

  • OTHER

  • Family History Questionnaire

    Page 4

  • Child/Adolescent Problem Checklist

    Please check if you have been experiencing any of the following symptoms/behaviors currently or over the past month.

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  • Should be Empty: