Developmental And Behavioral Pediatrics History

Developmental and Behavioral Pediatrics History (Biological, Social, Behavioral)

Child’s Name ______Age______Grade ______DOB ______

Phone ______Physician ______School/Teacher ______

Very often the history of your family and your child provides important information to help us understand current concerns. Please complete the following information as completely as you can.

A. Current and Past Concerns

What are your primary concerns for your child? (Please include any previous diagnoses.)

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B. Birth History

1. Prenatal Complications: ______

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A. Was your child unusually active during the pregnancy? ______

B. Was this pregnancy different from your others? ______

2. During or shortly before pregnancy, Maternal history was:

A. Medications: ______

B. Substance Use: Cigarettes ______Alcohol ______Drugs ______

C. Major Life Stress: ______

D. Medical Problems: ______

E. Surgeries: ______C. Medical History

1. Just after birth (neonatal) history: ______

A. Birth Weight ______B. Birth length______

C. APGAR Score ______D. Complications ______

2. Was the child born more than three weeks early or late? Yes ______No ______

3. Current health status? Good ______Not Good ______

Please explain: ______

A. Current medication being used (include Name/Dosage/Timing) ______B. Any significant head injuries? ______C. Any serious illnesses? ______D. Any chronic illnesses? ______E. Many ear infections? ______F. Any Allergies? ______G. Any history of seizures? ______H. Any vocal or motor tics? ______I. Are there vision concerns? ______J. Are there hearing concerns? ______K. Any hospitalizations? ______L. Injuries as a result of accidents? ______

4. Family Health/Mental Health History (Please review the health history of close family members: parents, grandparents, aunts, uncles, sisters, brothers, cousins).

A. Childhood onset diabetes? ______B. Thyroid disease? ______C. Depression disorder? ______D. Anxiety disorder? ______E. Alcohol or substance abuse? ______F. ADD, ADHD, or similar characteristics? ______G. Conduct problems? ______H. Exposure to lead? ______

D. Developmental History

1. When did you first become concerned about your child’s development? ______

______2. What happened that made you become concerned? ______

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3. At what age did your child: A. Sit up? ______B. Walk? ______C. Speak single words?______D. Speak short sentences? ______E. Sleep through the night? ______F. Toilet train bladder? ______G. Toilet train bowel? ______H. Remain dry through the night? ______

4. Which hand does your child prefer? Right ______Left ______Both ______

5. In comparison to other children his/her age, does your child seem awkward in physical activities (example: running, jumping, cutting paper, writing, etc.)? ______

If so, please specify and explain. ______

______

6. Describe your child’s ability to develop habits and consistent behaviors: A. Eating ______B. Sleeping ______C. Toileting ______

7. Describe your child’s temperament, “general approach to the world”. For example: easy going, irritable, happy, flexible, etc. ______

______

8. Does your child remind you of any other family members? ______

Please explain: ______

9. Is your child’s development: A. Moving forward ______B. Stable ______C. Declining ______E. Family History and Home Environment

1. Household Information:

Family Members Lives With Child Family Members School Birthday Yes No or Health Problems

Father ______Mother______Guardian ______Brothers’ ______(In order of age) Sisters’______(In order of age) Others ______

2. Significant Family Events: A. Since your child’s birth, has the family had any major difficulty such as divorce, death, separation, or remarriage? Yes______No ______If so, please specify: ______B. Have you worked either full-time or part-time since your child was born?______If so, when did you start that job? ______How long did you continue? ______Who took care of your child during this time? ______START STOP CARETAKER ______C. Have there been any other events that you think might have had some influence on your child’s behavior or development? ______If so, please specify: ______D. Do you have babysitters from time to time? ______If so, how often? ______Is it usually the same person or does it vary? ______

3. Do family members get along? ______

4. How would you describe your home? VERY ORGANIZED ______AVERAGE ______DISORGANIZED ______5. How would you describe your discipline standards? STRICT ______MODERATE ______PERMISSIVE ______

6. How would you describe your discipline style? CONSISTENT ______INCONSISTENT ______

F. Educational History

1. Current Grade ______School ______Teacher ______

2. Academic difficulty was first noted in ______grade.

3. A grade was repeated in ______

4. Areas of academic strength are: ______

5. Areas of academic weakness are: ______

6. Current special education classification is: ______

7. Accommodations to regular education are: ______

8. Special education support services are: ______

9. Is your child liked by his/her teachers? ______

10. School and classroom behavior is: ______

G. Social Adjustments

1. Does your child get along well with: Brothers/sisters? ______Children his/her own age? ______Older children? ______Younger children? ______Adults? ______

2. Does your child prefer to play alone or with other children? ______

3. Does he/she often get into fights with other children? ______

4. Is the child competitive with other children or with his/her brothers and sisters? ______5. Is the child easily frustrated? ______6. How does your child respond to frustration? ______

7. Is your child affectionate? ______

8. How does your child respond to affection? ______

9. Does the child insist on getting his/her own way? ______

10. Does he/she throw temper tantrums? ______If so, when? ______

11. Is your child shy? ______Does your child talk a lot? ______

12. Does your child daydream frequently? ______If so, what are they about? ______

13. Does he/she seem happy (laugh and smile much)? ______

14. Describe his/her favorite hobbies or interests. ______

15. What does your child do best? ______

16. What doe he/she most enjoy doing? ______

17. Is the child very active? ______Is the child sluggish? ______

18. Describe your child’s ability to follow the rules. ______

19. Describe your child’s ability to think before taking action. ______

20. Describe you child’s ability to wait for pleasurable events/objects. ______

21. Does your child generally feel lonely or different? ______

22. Behavior in the neighborhood is generally positive or negative, please explain. ______

23. Behavior is/is not age appropriate, please explain. ______24. My child enjoys the following activities. ______25. Paying attention is/is not easy for my child. ______

26. It is/is not hard for my child to resist distraction. ______

27. How would you describe your child in general? ______

Add Additional Information That You Feel Will Be Helpful In Evaluating Your Child

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