Fillable Psychology Developmental History Sheet.xls

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Psychology Developmental History Sheet.xls

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Please Print
1.
a) During this pregnancy did the mother experience any unusual illness, condition or accident such as German measles,
RH incompatibility, false labor, etc.? If so, please describe:
b) Was the mother taking any drugs during pregnancy? If yes, please list:
How Many Times has the child moved?
4.
3.
2.
Age
Education
1.
Siblings:
Others Living With Family:
Name
DOB
3.
4.
Name DOB
1.
2.
Age
Education
Education
Marital Status Education Occupation
Marital Status
Name of Father
Age
Occupation
AgeDOB
Name of Mother
Age GradeDOBName of Child
DOB
DEVELOPMENTAL HISTORY
Pregnancy and Birth:
Mid-State Health Center Psychology
Were there any problems with delivery such as breech birth, Caesarian section, etc? If so please describe:
3. Was the pregnancy planned?
2. Length of Pregnancy Duration of labor: Birth Weight:
At what age did the following occur:
Age of walking
Were there any feeding problems? If yes, please describe:
Age of talking
Age of toilet training Dressed and undressed self
Describe infant's temperament:
Did the child have difficulty with strangers or separating from parents?
Were there any developmental problems or concerns? If yes, please explain:
Describe accidents or operations the child has had:
Describe any hospitalizations:
Were there any medical problems other than normal childhood illnesses? If yes, please explain:
Feeding:
Developmental:
Medical History:
No
Were any of these illnesses followed by noticeable changes in the child's general behavior or in his/her speech?
Results:
Results:
If so, please describe:
Have the child's eyes been examined?
Have the child's ears been examined?
Names of medications and dosages:
How long has the child taken the medications?
Is the child under the care of a doctor? Does he/she presently take medication?
What was the child's reaction?
Child's Physician: Address:
Has your child had any psychological testing? When and where?
For what reason?
When and where?Has your child had a neurological examination?
Grade:
For what reason?
Did the child attend Nursery School? Kindergarten?
Teacher:
What are his/her usual grades in the following subjects?
Math: Reading: Spelling:
School Attending:
Grades Failed? Grades Skipped?
Does the child have an Individual Education Plan, or is he/she coded?
Is the child frequently absent from school? If yes please explain:
Education History:
No
No
No
No
No
No
No
No
Does your child have nightmares? Does he/she have fears?
Does your child sleep well? Eat well?
Does he/she tend to play alone or with other children?
How does he/she get along with adults?
Is it difficult to discipline the child? (Explain as fully as possible)
Would you describe the child as basically happy or unhappy?
Does your child have difficulty in concentration?
What are his/her favorite play activities?
Addition comments on behavior:
Describe relationship with mother, father, and siblings:
Name of Guardian: Telephone #:
Name of Person Completing this Form:
Daily Behavior:
No
No
No
With other children
No
No
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Psychology Developmental History Sheet.xls

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Completed 4 October 2021

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