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

Date

Age

Gender

Child' school:

Grade

Special placement (if any)

Child is presently living with (click all that apply):

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?

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?

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:

Please provide details of any complications checked above

Other pregnancy related concerns:

Please provide details of any complications checked above

INFORMATION ABOUT DELIVERY

Duration of delivery (hours)

Type of labor:

Type of delivery:

Complications:

Other

Number of days in the hospital after delivery:

Post-delivery complications:

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?

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:

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.

Rows	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:

Rows	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?

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:

Rows	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

Rows	Grade level
Reading
Spelling
Arithmetic

Has your child ever had to repeat a grade?

If SO, when?

Present class placement:

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:

Rows	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:

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:

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.

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: