Child Health History Form

Developmental History
Where was child born?
Length of Pregnancy
(i.e., 9 months)
Child's Weight at Birth
(i.e., 8 lb 2 oz)
Briefly explain any problems with the pregnancy or delivery:
Any known alcohol or substance abuse during pregnancy?
If Yes, briefly describe:
Briefly describe any health problems at birth (if applicable):
Was infant hospitalized for any length of time after birth?
If Yes, briefly describe:
(i.e., how long, for what purpose/concern)
Describe any early developmental delays in walking, talking, potty training, etc.
When did child speak their first word(s)?

Has the child received any of the following interventions?

Yes - Currently?

Yes - In the Past?

If yes, how long did they receive the service?

Speech Therapy

Physical Therapy

Occupational Therapy

Medical History
Date of child's last visit to the pediatrician

Month Day Year
Date
Describe if there were any concerns at that time:
If available, please upload (or provide a photo of) the most recent medical summary from the last visit (some insurance companies are requesting this for prior approval):

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Medical record photo:
Does your child have hearing or vision issues?
If Yes, are they corrected (with glasses, contact lenses, hearing aids, etc.)?
Describe any hospitalizations the child has experienced for general medical reasons:
(i.e., when and why did they occur, for how long, any lasting concerns?)
Briefly describe any surgeries the child has experienced:
(i.e., when and why did they occur, any lasting concerns?)
Briefly describe any chronic illnesses or concerns for your child:
(i.e., diabetes, asthma, etc.)
Check all of the known allergies for this client:

Pollen/Seasonal Medication - specify below Food - specify below Other substance - specify below
Describe medication, food, or other allergies the child experiences:
What medication, food, or other substance is the child allergic to?
What medications (non-psychiatric) does the child CURRENTLY take?
Provide names, dosages, and condition they treat if applicable.
Has your child ever had any head injuries?
If Yes, briefly describe:
When did the injury occur, any concussion or medical treatment needed, any lasting concerns, etc.?
Has your child had any appetite problems or changes in weight in the past several months?
If Yes, briefly describe:
Does your child have any sleep problems or nightmares?
If Yes, briefly describe:
(i.e., How often are there problems or nightmares - nightly, weekly, month? What are the nightmares about? Is there trouble falling or staying asleep?)

Educational History
Name of child's school:
What grade is he/she in?
Current or most recent academic grades:
(i.e., As, Bs, etc.)
If available, please upload or take a photo of the most recent progress/report card, IEP, or school records (some insurance companies are requesting this to be reviewed for prior approval):

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Academic record photo:
Has your child repeated any grades? (if yes, which ones?)
Check any special educational services your child has received (past or present).

IEP - Individual Education Program or Plan RTI - Response to Intervention 504 Plan for Accommodations No special educational services have been provided
Why have they received special educational services? (choose all that apply)

Behavioral Concerns or Disorder Emotional Problems Educational or developmental problems
Please describe any special educational services or special accommodations your child receives currently in school?
(i.e., Extra time on tests; one on one support; self-contained class; pull outs for specific subjects; etc.)
How many times has the child been suspended or expelled from school in their lifetime?
Please describe the reason for the child's suspensions or expulsions:
(i.e., When was the last time; For what reason(s), What have teachers said about behaviors or issues in school, if applicable)

Child Health History Form

Developmental History

Medical History

Family History

Educational History

Mental Health History