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Child Development HxDerek Judkins2019-05-23T15:36:35-06:00

Child And Adolescent History Form

Step 1 of 13

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General Information
Name*
First Last
Phone
Email

Date of Birth*
Date Format: MM slash DD slash YYYY

Gender*
Nationality*
Name of person completing form*
First Last
Relationship to child*
Reason for referral: What are your primary concerns?*

Parents & Family
Parent 1 Name
Level of Education
Occupation
Employer
Parent 2 Name
Level of Education
Occupation
Employer
Parents are*
Married
Never Married
Separated
Divorced
Living Together
Other
Legal Custody*
Joint
Mother
Father
County
Foster Parent
Other
Physical Custody*
Joint
Mother
Father
County
Foster Parent
Other

Other Parent(s)/Stepparent(s)/Caregiver(s)
Name
Relationship to child
Name
Relationship to child

Please list all siblings or others living with the family
Name
Relationship
Age
Name
Relationship
Age
Name
Relationship
Age

Please list all siblings not living in the home
Name
Relationship
Age
Name
Relationship
Age
Name
Relationship
Age
Has your child experienced neglect or abuse?
Yes
No
Suspected
Unknown
If there has been any abuse or trauma experienced check all that apply.
Physical Abuse
Sexual Abuse
Emotional Abuse
Verbal Abuse
Bullying
Life-Threatening Situation
Other Trauma
Has your child ever lost someone with whom s/he had a close relationship, (e.g. a parent, sibling, etc.)?
Have there been any recent stressful life events? (Check all that apply)
Divorce/Separation
Financial Problems
Substance Abuse
Death of Family/Friend/Pet
Marriage
Change in Job Status
Disagreement About Parenting
Relationship Conflict
Sibling Conflict
Other

Birth History
Mother’s age at time of child's birth:
Did mother receive prenatal care?
Medications taken during pregnancy? (Please specify):
Were any of the following used during pregnancy? (Including prior to knowledge of the pregnancy)
Alcohol
Marijuana
Tobacco
Methamphetamines
Other Drugs
Please explain any complications during pregnancy, labor or delivery
Method of delivery (vaginal, cesarean, forceps, vacuum)
Full term/early/late
Child’s birth weight and length
Were there any complications before the baby was taken home?
Did the baby spend any time in the NICU, and if so for what?
Any additional comments
Any history of foster care/orphanage care/CPS involvement?
If child is adopted, Age at adoption
Contact with biological parents?
Additional comments

Developmental History
Which hand does your child prefer
Right
Left
Did your child ever have any motor coordination difficulties (e.g. frequent falling, awkwardness)?
Yes
No
Did your child have any difficulty in learning to talk or have any speech problems?
Yes
No
At what age did your child develop gross motor skills (crawling, walking)?
At what age did your child develop fine motor skills (fingers / hands)?
At what age did your child develop communication skills?
At what age did your child develop self-care (dressing self, taking care of hygiene)?
At what age did your child develop social skills?
At what age did your child develop education skills (alphabet, numbers)?
At what age was your child toilet trained?
Has your child had problems with the following? (Check all that apply)
Limited social interest
Narrow range of interests
Self-harm
Withdrawn behavior
Repetitive or odd behaviors
Aggressive behaviors
Tantrums
Loss of developmental skills
Shyness
Poor eye contact
Limited self-regulation
Specific fears
Additional Comments

Medical History
Does your child have or has s/he ever had meningitis?*
Yes
No
Does your child have or has s/he ever had head injuries/concussions?*
Yes
No
Does your child have or has s/he ever had ear infections?*
Yes
No
Does your child have or has s/he ever had asthma?*
Yes
No
Does your child have or has s/he ever had diabetes?*
Yes
No
Does your child have or has s/he ever had loss of consciousness?*
Yes
No
Does your child have or has s/he ever had high fever?*
Yes
No
Does your child have or has s/he ever had heart disease?*
Yes
No
Does your child have or has s/he ever had seizures?*
Yes
No
Does your child have or has s/he ever had lead poisoning?*
Yes
No
Does your child have or has s/he ever had any other Illness?*
Yes
No
Please describe treatment given and any complications for illnesses/injuries indicated above
Has your child ever been hospitalized?*
Yes
No
Describe any hearing or vision problems
List any previous surgeries, child’s age, and length of hospitalization
Other medical history
Does your child frequently complain of or have problems with (check all that apply)
Headache
Weakness
Fatigue or Sleep Issues
Dizziness
Nausea
Wetting/Soiling Accidents
Stomach Aches
Diarrhea
Muscle Tension
Current Medications
For what has this medication been prescribed?
Side Effects
Who prescribes this medication?
Previous medications & dates taken
Has anyone in your family had a neurological disease?*
Yes
No
Has anyone in your family had seizures (epilepsy)?*
Yes
No
Has anyone in your family had psychiatric problems?*
Yes
No
Has anyone in your family had emotional problems?*
Yes
No
Has anyone in your family had alcoholism problems?*
Yes
No
Has anyone in your family had substance abuse problems?*
Yes
No
Has anyone in your family had language delays?*
Yes
No
Has anyone in your family had motor (physical) delays?*
Yes
No
Has anyone in your family had hyperactivity?*
Yes
No
Has anyone in your family had learning problems?*
Yes
No
Has anyone in your family had autism spectrum disorders?*
Yes
No
Has anyone in your family had similar problems to child?*
Yes
No

Evaluation & 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 Evaluation
Occupational Therapy/Physical Therapy/Speech & Language Therapy
Clinic Name & Examiner's Name
Therapy: Dates attended
Dates of Last Vision/Hearing Examination
Neurologist's Name
Date of Last Examination
County Social Worker/Case Manager Name
Telephone
Fax
Other

School
Name of Child’s Current School
Grade
Main Teacher or Counselor
Has your child completed an evaluation through school (e.g., to qualify for special education)?*
Yes
No
Name of Preschool
Dates Attended
Concerns
Name of Elementary School
Dates Attended
Concerns
Name of Middle/Junior High School
Dates Attended
Concerns
Name of High School
Dates Attended
Concerns
Has your child received Title 1 services?*
Yes
No
Has your child had a 504 plan?*
Yes
No
Has your child had an IEP (special education services)?*
Yes
No
Has your child received tutoring?*
Yes
No
Check the word that best describes your child’s grades throughout his/her school experience*
Superior
Above Average
Average
Below Average
Failing
Has school reported current problems with (check all that apply)
Reading
Arithmetic
Social Adjustment
Writing
Attention Span
Following Directions
Spelling
Activity Level
Truancy
Suspension
Detention
Other

Emotional/Behavioral Concerns
Does your child have a history or currently struggle with (check all that apply)
Depression/Sad Mood
Anxiety/Worries/Nervousness
Anger
Attention and Focus Issues
Significantly Elevated Moods
Ritual or Routine Behaviors
Obsessive Thinking
Hallucinations
Suicidal Ideation
Self-Harm Behaviors
Homicidal Ideation
Rule Breaking
Argumentative
Social Concerns
Hyperactivity
Temper Tantrums
Irritability
Panic Attacks
Impulsivity
Distressing Memories
Separation Issues
Complaints of Physical Symptoms
Nightmares
Eating Issues

Substance Use History
Has your child used alcohol?*
Yes
No
Has your child used cannabis?*
Yes
No
Has your child used meth?*
Yes
No
Does your child consume caffeine?*
Yes
No
Has your child ever participated in inpatient or outpatient chemical dependency treatment?*
Yes
No

Interpersonal Relationships
Your child's relationship status
Your child's Sexual Orientation/Gender Identity

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