Adult Development Hx – Nystrom & Associates

Developmental History
Which hand do you prefer*
- Right
- Left
Did you ever have any motor coordination difficulties (e.g. frequent falling, awkwardness)?*
- Yes
- No
Did you have any difficulty in learning to talk or have any speech problems?*
- Yes
- No
At what age did you develop gross motor skills (crawling, walking)?
At what age did you develop fine motor skills (fingers / hands)?
At what age did you develop communication skills?
At what age did you develop self-care (dressing self, taking care of hygiene)?
At what age did you develop social skills?
At what age did you develop education skills (alphabet, numbers)?
At what age were you toilet trained?
Additional Comments

Evaluations & Services
For each category, please list any previous evaluations, examiners, dates, and results, as well as current providers.
Pediatrician or Family Doctor
Telephone
Fax
Therapist/Examiner's Name
Title
Telephone
Fax
Dates of Last Evaluation/Sessions
Date of Occupational Therapy/Physical Therapy/Speech & Language Evaluation
Clinic Name & Examiner’s Name
Therapy: Dates attended
Date of Last Vision/Hearing Examination
Neurologist's Name
Date of Last Examination
County Social Worker/Case Manager Name
Telephone
Fax

Adult History Form