Child Health and Developmental History

Child Identification Information

Name of child:                                                       B-Date:


Parents names:

Siblings names / ages in birth order:

Home phone:

Parent work phone:

Home address:

Emergency contact & phone number:

Referral source (“How did you get my name?”):

Days and times preferred:

Current school & grade:

Financial information: How  will you be paying for services (circle: Cash, Credit, Check)

Child Developmental History

Please fill in any information you have on the areas listed below (Only if relevant)

Pregnancy and delivery outcome:

Prenatal medical illnesses and health care:

Was the child premature? Weight and height at birth:

Any birth complications or problems?

The first few months of life

Sleep patterns or problems:

Personality or temperment:

Milestones: Any delays in the following (Sitting without support, crawling, walking, dressing, toilet trained, eating with utensils, stayed dry at night, dressing, language development, other …..)

Any speech, hearing, or language difficulties, or developmental delays?

Overall Health

List all childhood illnesses, hospitalizations, medications, allergies, head trauma, important accidents and injuries, surgeries, periods of loss of consciousness, convulsions/seizures, and other medical conditions.


Condition                          Age                                      Treated by whom?




Any residential placements, institutional placements, special schools, or foster care Dates

From            To

Reason for placement


Special skills, talents of interests of child:

List hobbies, sports; recreational, TV, and toy preferences; etc.:

Current Information:

  1. Unusual Weight changes
  2. Headaches (location, type, )
  3. Dizzy Spells, Seizures, Petit Mal Seizures, Neurological Concerns
  4. Gait & Coordination problems
  5. Sensory Difficulties (vision, smell, hearing, proprioception)
  6. Personality Changes (mood, behavior, anxiety, apathy, hyperactivity)
  7. Head Traumas, accidents, toxic exposures, infections
  8. Birth Defects
  9. Genetic History (familial)
  10. Immunity (frequent colds, flus, )
  11. Elimination health (diarrhea, constipation, nausea, enuresis, encopresis)
  12. Muscle twitching, tics, movement d/o
  13. Handedness (left / right)
  14. Ability to concentrate and attend
  15. Behavior (compliant, bossy, defiant, )
  16. Temperment (current)
  17. Drooping of facial muscles or eyelids
  18. Range of motion of head
  19. Strengths and weaknesses (physical and mental)
  20. Strange behaviors
  21. Dietary habits and typical meals
  22. Behavioral changes related to time of day, season, weather, environment
  23. Family Dynamics and environment
  24. Neighborhood and school environment
  25. Post-traumatic stress or traumatic event exposure
  26. Ability to relate to peers and adults
  27. Anxiety (social, school, phobias, obsessive compulsive d/o, separation, etc.)
  28. Parent-child interaction
  29. Eating disorders (pica, malnutrition, anorexia)
  30. Allergies

Treatment: Has your child ever received psychological or psychiatric or counseling services before?           No  Yes

When?                     From whom?                       For what?                       With what results?


Has your child ever taken medications for psychiatric or emotional problems?           No  Yes

When?             From whom?         Which medications            For what               With what results?


Current medication                Dosage                       How long have you been taken this medication


Date of your child’s last physical exam, general health:


Current Medical / Psychological and other health care providers

Name                 Specialty                Address                            Phone #               Date of last visit



Chief concern : Please describe the main concern you have with your child at this time:


When did your child’s problems begin?


What was happening just prior to the time that may have contributed to the current problems?


Who is involved or affected by this problem? How are they involved?


What have you tried so far to handle the problem?


What has worked? When is it worse – when is it better?


Have there been any previous episodes of this problem? If so, what brought the problem on & how did you resolve it?


Does your child smoke (how much), drink, use drugs, caffeine, : Please Indicate:


How does your child feel about school?


How is your child’s relationships with peers, spouse, children, family


What can I do for you? How can I be of assistance?


How long will it take? How will we both know when we are successful?


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