To be completed by parent or guardian. The information you provide to us will be very helpful in treating your child. Please fill out completely. If you have any difficulty, complete as much as possible. Thank you!
Was the child planned? blanks Wanted?blankFull-Term?blank If not full term, what month born? blanks Please describe the mother's health during the pregnancy. Any complications, accidents, or drugs used? blankWere there any difficulties in living situation or marriage during pregnancy?blanksblanks Any problems with labor? blank Any problems with birth?blankWere drugs or instruments used during birth? If so, which ones?blanksIf the child was adopted, please answer the following questions:What information do you know about the biological parents? Age of adoption?blankWas the child informed about the adoption? If so, when?blank
Which parent usually disciplined the child?blanks How? blank Was this effective? blank Were there times that discipline got out of control? blanks Is there any history or knowledge of child abuse? (physical, emotional, or neglect) blanks
Baby's weight at birth: blanks Mother's/baby's condition right after the birth (list any problems/complications): blank If baby was unplanned or unwanted, did it change after the birth?blank Was baby breastfed or bottle-fed?blankAny problems with feeding? (Colic, splitting up, never seemed satisfied, weight problems): blankDid baby like to be held or cuddled? blankDescribe sleeping problems (excessive sleep, difficulty falling asleep, difficulty staying asleep, bed wetting, sleep walking): blankPlease describe the onset of bedwetting (frequency): blankWhen did the baby first start to crawl? blankFirst started to walk? blank First started to talk? blankFirst formed sentences?blank Age when toilet training began?blankCompleted?blankAny problems with toilet training or accidents afterward? blankWas the child curious as a child? blank Was the child hyperactive or underactive?blankWas the child particularly active in ways that made you bring them to a physician?blankWas the child accident prone? blankWas the child destructive as a young child? blankIf any temper tantrums, how were they handled? blankAny tendencies to approach or withdraw from new situations? blankAny specific fears, phobias, nervous habits? blankDid or does your child become frustrated easily? blankDid or does your child seem to under or overreach to situations? (new person, wet diaper, hunger, etc.) blankHow would you describe your child's usual mood? (passive, irritable, slow to warm up, cheerful) blankDescribe your child's attention span (easily distracted, attentive to activities, etc.): blank Good or poor sense of motor coordination? blank When did your child first learn to ride a tricycle? skate? blankWhen did your child start writing legibly? blankManipulate small toys or puzzles? blank Dress self? blank
How old was your child when they entered school? blanksAny problems with separating from parents?blank Any difficulties in kindergarten? (Please specify) blanks What was the child's average grade on report card in elementary school? blank Was your child involved in any organized activities (i.e. Scouts or Little League)? blanksIf so, how long and what was the reason for discontinuing? blanks Were there any behavioral issues in elementary school? Please describe what, when, and how often. blankHave any neighbors or others complained about your child's behavior? blankWhat was the average grade on report card during junior high? blankDoes your child currently have any behavioral problems in school? If so, when did it start and what are they? blankHow have you and the school dealt with them? Has it helped?blank
What is/was their average grade on the report card in high school? blanksDoes your child currently have any behavioral problems with school? If so, when did it start and what are they? blank Did your child begin to show biological symptoms of growth and developments of a teenager? (i.e. body/facial hairs, menstrual cycle, voice change) Please indicate when: blankHave you discussed reproduction and sexuality with your child? blankHow does your child get along with other younger children of the same sex?blankAny lasting friendships? blankDoes your child have friends of the opposite sex? blank Is your child sexually active? blankDoes your child belong to any special peer groups or gangs? blankDoes your child use drugs/alcohol? If so, for how long? blankHas your child suffered any sexual abuse and/or trauma? blank
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.