Child Development HxDerek Judkins2019-05-23T15:36:35-05:00 Child And Adolescent History Form Step 1 of 13 7% General InformationName* First Last PhoneEmail 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 & FamilyParent 1 NameLevel of EducationOccupationEmployerParent 2 NameLevel of EducationOccupationEmployerParents are*MarriedNever MarriedSeparatedDivorcedLiving TogetherOtherLegal Custody*JointMotherFatherCountyFoster ParentOtherPhysical Custody*JointMotherFatherCountyFoster ParentOther Other Parent(s)/Stepparent(s)/Caregiver(s)NameRelationship to childNameRelationship to child Please list all siblings or others living with the familyNameRelationshipAgeNameRelationshipAgeNameRelationshipAge Please list all siblings not living in the homeNameRelationshipAgeNameRelationshipAgeNameRelationshipAgeHas your child experienced neglect or abuse?YesNoSuspectedUnknownIf 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 HistoryMother’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 deliveryMethod of delivery (vaginal, cesarean, forceps, vacuum)Full term/early/lateChild’s birth weight and lengthWere 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 commentsAny history of foster care/orphanage care/CPS involvement?If child is adopted, Age at adoptionContact with biological parents?Additional comments Developmental HistoryWhich hand does your child preferRightLeftDid your child ever have any motor coordination difficulties (e.g. frequent falling, awkwardness)?YesNoDid your child have any difficulty in learning to talk or have any speech problems?YesNoAt 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 HistoryDoes your child have or has s/he ever had meningitis?*YesNoDoes your child have or has s/he ever had head injuries/concussions?*YesNoDoes your child have or has s/he ever had ear infections?*YesNoDoes your child have or has s/he ever had asthma?*YesNoDoes your child have or has s/he ever had diabetes?*YesNoDoes your child have or has s/he ever had loss of consciousness?*YesNoDoes your child have or has s/he ever had high fever?*YesNoDoes your child have or has s/he ever had heart disease?*YesNoDoes your child have or has s/he ever had seizures?*YesNoDoes your child have or has s/he ever had lead poisoning?*YesNoDoes your child have or has s/he ever had any other Illness?*YesNoPlease describe treatment given and any complications for illnesses/injuries indicated aboveHas your child ever been hospitalized?*YesNoDescribe any hearing or vision problemsList any previous surgeries, child’s age, and length of hospitalizationOther medical historyDoes 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 MedicationsFor what has this medication been prescribed?Side EffectsWho prescribes this medication?Previous medications & dates takenHas anyone in your family had a neurological disease?*YesNoHas anyone in your family had seizures (epilepsy)?*YesNoHas anyone in your family had psychiatric problems?*YesNoHas anyone in your family had emotional problems?*YesNoHas anyone in your family had alcoholism problems?*YesNoHas anyone in your family had substance abuse problems?*YesNoHas anyone in your family had language delays?*YesNoHas anyone in your family had motor (physical) delays?*YesNoHas anyone in your family had hyperactivity?*YesNoHas anyone in your family had learning problems?*YesNoHas anyone in your family had autism spectrum disorders?*YesNoHas anyone in your family had similar problems to child?*YesNo Evaluation & ServicesFor each category, please list any previous evaluations, examiners, dates, and results, as well as current providers.Pediatrician or Family DoctorTelephoneFaxTherapist/Examiner's NameTitleTelephoneFaxDates of Last Evaluation/SessionsDate of EvaluationOccupational Therapy/Physical Therapy/Speech & Language TherapyClinic Name & Examiner's NameTherapy: Dates attendedDates of Last Vision/Hearing ExaminationNeurologist's NameDate of Last ExaminationCounty Social Worker/Case Manager NameTelephoneFaxOther SchoolName of Child’s Current SchoolGradeMain Teacher or CounselorHas your child completed an evaluation through school (e.g., to qualify for special education)?*YesNoName of PreschoolDates AttendedConcernsName of Elementary SchoolDates AttendedConcernsName of Middle/Junior High SchoolDates AttendedConcernsName of High SchoolDates AttendedConcernsHas your child received Title 1 services?*YesNoHas your child had a 504 plan?*YesNoHas your child had an IEP (special education services)?*YesNoHas your child received tutoring?*YesNoCheck the word that best describes your child’s grades throughout his/her school experience*SuperiorAbove AverageAverageBelow AverageFailingHas 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 ConcernsDoes 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 HistoryHas your child used alcohol?*YesNoHas your child used cannabis?*YesNoHas your child used meth?*YesNoDoes your child consume caffeine?*YesNoHas your child ever participated in inpatient or outpatient chemical dependency treatment?*YesNo Interpersonal RelationshipsYour child's relationship statusYour child's Sexual Orientation/Gender Identity
