Fillable DEVELOPMENTAL HISTORY FORM 2016

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DEVELOPMENTAL HISTORY FORM 2016

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DEVELOPMENTAL HISTORY
Child’s name:_____________________________________________________
History obtained by:________________________________________________
Birthday:__________________________ Age:__________________________
Telephone:_________________________Date:__________________________
Address:__________________________________________________________
FAMILY:
Mother’s name:__________________________ Occupation:_________________
Father’s name:___________________________ Occupation:_________________
Ages of male siblings:_________________________________________________
Ages of female siblings:________________________________________________
Who resides in the home:_______________________________________________
FAMILY HISTORY:
Are any of your child’s siblings in special classes or receiving any type of therapy?
____________________________________________________________________
Has anyone in your family ever had any speech or learning di
fficulties?
____________________________________________________________________
Prenatal care began at__________Month
Mothers RH factor_________________
DID MOTHER HAVE ANY OF THE FOL
LOWING DURING PREGNANCY?
*GIVE MONTH
NO YES EXPLAINATION
RUBELLA _____ _____ _______________________
HIGH FEVERS _____ _____ _______________________
BLEEDINGHIGH BP _____ _____ _______________________
EDEMA _____ _____ _______________________
ACCIDENTS _____ _____ _______________________
EXCESSIVE _____ _____ _______________________
VOMITING _____ _____ _______________________
HOSPITALIZATIONS _____ _____ _______________________
SURGERY _____ _____ _______________________
ILLNESS _____ _____ _______________________
DRUGS _____ _____ _______________________
DELIVERY:
Birth weight__________________ Full term_______________Premature____________
Duration of Labor_____________ Presentation_________________________________
(Head,breech,caesarean)
Anesthesia was general______________________
Anesthesia was: Local____________Spinal______________None used_____________
Were there any complications? (Infections, hem
orrhage, cord around neck etc.)
NO____________YES____________ Explain:
________________________________________________________________________
________________________________________________________________________
Did the baby cry immediately? YES_____________ NO________________
Was Oxygen given? YES___________ NO_________________
Were there any obvious birth injuries or abnorm
alities?
________________________________________________________________________
Any feeding problems?_____________________________________________________
Was the baby nursed or bottle fed?____________________________________________
Baby healthy and alert (no problems)__________________________________________
Did the baby go home on the same day as the mother?____________________________
DEVELOPMENTAL HISTORY:
(Give approximate age of occurrence by month or year)
Held head up____________________Feed self with spoon_________________
Sat alone_______________________Bowel training initiated_______________
Crawled________________________Bowel training completed_____________
Walked alone____________________Assist with dressing_________________
Spoke first word__________________Spoke sentences____________________
Energy Level is: High_______ Low________Average___________
Small muscle coordination is : Better than average______ Average_______ Poor_____
Large muscle coordination is : Better than average______ Average________Poor_____
Is there anything unusual about the child’s gait?________________________________
SPEECH LANGUAGE AND HEARING DEVELOPMENT:
Language spoken at home:__________________________________________________
Does the child prefer to talk_________gesture________ both talk and gesture_________
Does the child most frequently use sounds_______single words_______2 word sentences
____________3 or more word sentences______________
Did speech learning ever seem to stop for a period of
tim
e?___________________________________________________________________
Does the child understand what you say to him or her?____________________________
Can he or she follow simple commands?_______________________________________
CHILD’S MEDICAL HISTORY:
No Yes Age and Details
Allergies ___ ___ _______________________
Mumps ___ ___ _______________________
Measles ___ ___ _______________________
Rubella ___ ___ _______________________
Meningitis ___ ___ _______________________
Encephalitis ___ ___ _______________________
Ear Infections ___ ___ _______________________
High Fevers ___ ___ _______________________
Seizures ___ ___ _______________________
When was the last seizure?___________________________________________
What kind of seizure was it?__________________________________________
Does the child have any medical condition such as cerebral palsy, diabetes, asthma etc.?
Please list:_______________________________________________________________
________________________________________________________________________
No Yes Date
Head injuries ___ ___ ______
Serious accidents ___ ___
______
EEG and /or X-rays ___ ___
______
Other illness, surgery etc. ___ ___
______
Who are your child’s physicians?(Give name, address of physicians
and dates last seen)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Current medication (include name, amount, times daily___________________________
Has the child ever had their vision or hearing tested? If so what were the results?
________________________________________________________________________
________________________________________________________________________
STATEMENT OF THE PROBLEM:
Describe in your own words what problem your child is having with speech, language,
hearing, feeding and/or motor skills:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
When was the problem first noticed?__________________________________________
Who noticed the problem?__________________________________________________
What changes if any in your child’s developm
ent have you noticed since then?
________________________________________________________________________
Do you have any thoughts on the cause of the problem? If so, please describe:
________________________________________________________________________
________________________________________________________________________
Has your child ever received a developmental or speech/langu
age evaluation before?
If yes what recommendations were given?
________________________________________________________________________
Has your child ever or is currently receiving any therapy/services (e.g. speech therapy
occupational therapy, physical therapy etc.)?_________________________________
PARENTS DESCRIPTION OF CHILD’S BEHAVIOR (Check off appropriate
statements):
____Outgoing ____Im
pulsive ___ Seeks approval
____Shy ____Cooperative ___Destructive
____Sensitive ____ Happy Child ___Cries often
____Fights often ____Friendly
___Separates easily
____Easily Frustrated ____Fearful ___Needs rem
inders
____Repeats sounds or words over and over
____Strong reactions to changes in routine or environm
ent
____Displays sense of humor
____Severe temper tantrums and/or frequent m
inor tantrums
____Gets along well with others
SOCIAL AND EMOTIONAL:
What concerns you most about your child?
________________________________________________________________________
________________________________________________________________________
What pleases you most about your child?
________________________________________________________________________
________________________________________________________________________
All information is confidential
Thank you for your time
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DEVELOPMENTAL HISTORY FORM 2016

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Completed 29 August 2021

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