Developmental History Form

AUBREY K. EWING, PH.D. & ASSOCIATES, P.A.
1230 So. Federal Hwy, Boynton Beach, FL 33435
561.742.7122 | Fax 561.742.7452
Email: contact@drewingonline.com
CHILDHOOD HISTORY FORM

Please answer all of the following questions to the best of your knowledge. The information you provide is essential in helping your doctor formulate a diagnostic impression of and treatment plan for your child. The answers you provide on this form are considered protected health information (PHI) and will be kept secure and confidential as required by HIPAA regulations.
Provide an email address to which we can confirm receipt of this form
example@example.com
Child's Name

First NameLast Name
Date of birth

MonthDayYear
Date
Age
Gender
Child' school:
Grade
Special placement (if any)
Child is presently living with (click all that apply):

Natural MotherNatural FatherStepmotherStepfatherAdoptive MotherAdoptive FatherFoster MotherFoster Father
Non residential adults involved with this child on a regular basis:
Briefly describe primary concerns about this child:
INFORMATION ABOUT CHILD'S PARENTS
Mother's name

First NameLast Name
Occupation
Age
Age at time of pregnancy with child
Mother's education
Highest grade or year completed
Has child's mother experienced any of the following?

Learning problemsAttention problemsBehavior problemsMedical problems
Please use this space to provide detail about any of the items checked above:
If the child's mother or any of her blood relatives have experienced problems similar to those observed in your child, please provide detail in the space below:
Father's name

First NameLast Name
Occupation
Age
Age when child was born
Father's education
Highest grade or year completed
Has child's father experienced any of the following?

Learning problemsAttention problemsBehavior problemsMedical problems
Please use this space to provide detail about any of the items checked above:
If the child's father or any of his blood relatives have experienced problems similar to those observed in your child, please provide detail in the space below:
INFORMATION ABOUT SIBLINGS
Please provide the name and age of child's siblings and describe and medical, social, school, or mental health problems any have experienced
INFORMATION ABOUT PREGNANCY
Duration of pregnancy in weeks:
Complications:

Excessive vomitingHospitalization requiredExcessive staining/blood lossThreatened miscarriageInfection(s)ToxemiaSurgeries
Please provide details of any complications checked above
Other pregnancy related concerns:

Smoking during pregnancyAlcoholic consumption during pregnancyMedications taken during pregnancyX-ray or other imaging studies during pregnancy
Please provide details of any complications checked above
INFORMATION ABOUT DELIVERY
Duration of delivery (hours)
Type of labor:

SpontaneousInduced
Type of delivery:

NormalBreechCaesarean
Complications:

Cord around neckHemorrhageInfant injured during delivery
Number of days in the hospital after delivery:
Post-delivery complications:

JaundiceCyanosis (turned blue)Incubator careInfection
Please provide details of any delivery complications checked above
CHILD'S DEVELOPMENT - INFANCY PERIOD
Please check any of the following that your child experienced to a significant degree during the first few years of life?

Did not enjoy cuddlingWas not calmed by being held or strokedDifficult to comfortColicExcessive restlessnessExcessively irritableDiminished sleepFrequent head bangingDifficulty nursing
If you checked any of the boxes above, please provide detail regarding the problems your child experienced in the space below.
Please indicate if your child's medical history includes any of the following:

Childhood diseases (describe ages and any complication)OperationsHospitalizations for illnessHead injuriesConvulsions with fever without feverComaPersistent high feversEye problemsEar ProblemsAllergies or AsthmaPoisoningSleep problemsAppetite
Please provide details of each event checked above and the age when the incident or illness occurred:
PRESENT HEALTH/MEDICAL STATUS
Height:
Weight:
Illnesses or conditions for which the child is currently being treated:
Medications child is taking regularly (or has in the past):

If you can recall, record the age at which your child reached the following developmental milestones. If you cannot recall exactly, indicate Early, Normal, or Late.

	Age	Early	Normal	Late
Smiled
Sat without support
Crawled
Stood without support
Walked without assistance
Spoke first words
Said phrases
Said sentences
Bladder trained, day
Bladder trained, night
Bowel trained, day
Bowed trained, night
Rode tricycle
Rode bicycle (no training wheels)
Buttoned clothing
Tied shoelaces
Name colors
Name coins
Said alphabet in order
Began to read

COORDINATION

Rate your child as compared to others his age on the following skills/characteristics:

	Good	Average	Poor
Walking
Running
Throwing
Catching
Shoelace tying
Buttoning
Writing
Athletic abilities
Number of accidents

COMPREHENSION AND UNDERSTANDING
Do you consider your child to understand directions and situations as well as other children his/her age?
If you answered "no" to the question above, explain why in the space below:
How would you rate your child’s overall level of intelligence compared to other children?

Below averageAverageAbove average
EDUCATIONAL (SCHOOL) HISTORY
If you were concerned about your child's ability to succeed in kindergarten, explain why in the space below (if not, leave blank):

Rate your child's academic abilities/performance in the grade levels listed below:

	Good	Average	Poor
Nursery school
Kindergarten
Elementary school
Middle school
High school
Current grade

To the best of your knowledge, what grade level is your child functioning in the following subjects

	Grade level
Reading
Spelling
Arithmetic

Has your child ever had to repeat a grade?
If SO, when?
Present class placement:

regular classspecial class
If your child is in a special class or curriculum, please describe it below:
Describe any special counseling or remedial work your child is currently receiving:
Describe briefly any academic problems your child is experiencing in school:

How would you rate your child's behavior/conduct (cooperation, following rules, respect, socially appropriate, peer relations, responsibility) in the grade levels below:

	Good	Average	Poor
Nursery school
Kindergarten
Elementary school
Middle school
High school
Current grade

Please check any of the following that your child's teacher(s) report as significant Classroom behavior problems:

Doesn't sit still in his/her seatFrequently gets up and walks around the classroomSpeaks out of turn, shouts out, doesn't wait to be called onIs impatient, won't wait her/his turnDoesn’t cooperate well in-group activitiesTypically learns or socializes better in a one-on-one relationshipDoesn't respect the rights of othersHas difficulty paying attention during presentations, lectures, storytelling
Briefly describe any other classroom problems you child may have:
To the best of your recollection, please use the following space to provide a general description of your child's school progress in each grade.
Example: 1st grade - excelled, 2nd grade - attention problems started,
Please check the boxes in front of the statements that are true about your child:

Seeks friendships with peersPeers seek out my child for friendshipMy child plays with children primarily his or her own ageMy child tends to play with children younger than her/himMy child tends to play with children older than her/him
Describe briefly any problems your child may have with peers:
BEHAVIOR AT HOME
All children exhibit the behaviors listed below to some degree. Check those that you believe your child exhibits to an excessive or exaggerated degree when compared to other children his or her own age.

Fidgets with hands, feet or squirms in seatHas difficulty remaining seated when required to do soEasily distracted by extraneous stimulations (noises, movement, media)Has difficulty waiting his/her turn in games or group situationsBlurts out answers to questions before they have been completedHas problems following through with instructions (usually not due to opposition or failure to comprehend)Has difficulty paying attention during tasks or play activitiesShifts from one uncompleted activity to anotherHas difficulty playing quietlyOften talks excessivelyInterrupts or intrudes on others (often not purposeful or planned but impulsive)Does not appear to listen to what is being saidLoses things necessary for tasks or activities at homeBoundless energy and poor judgmentImpulsivity (poor self control)Frustrates easilyHistory of temper tantrumsTemper outburstsSloppy table mannersSudden outbursts of physical contact with other childrenActs like motor drives him or herWears out shoes more frequently than siblingsExcessive number of accidentsDoesn't seem to learn from experiences of consequencesPoor memoryA "different child"
Does your child create more problems, either purposeful or non-purposeful, within the home setting than his or her siblings? If yes, explain.
Does your child have difficulty benefiting from his experiences or consequences?
Types of discipline you use with your child:
Is there a particular form of discipline that has proven effective?
Have you participated in a parenting class or obtained other forms of information concerning discipline and behavior management?
INTERESTS AND ACCOMPLISHMENTS
What are your child's main hobbies and interests?
What are your child's areas of greatest accomplishment?
What does your child enjoy doing most?
What does your child dislike doing most?
List the names of other healthcare or mental health professionals you have consulted and those now involved in your child's care
Please write additional remarks you may wish to make regarding your child:
Should be Empty: