<p> ORALNDO BEHAVIORAL HEALTH CHILDREN’S HISTORY FORM</p><p>Name: ______Date: ______</p><p>DOB: ______/______/______AGE: ______DATE SEEN: ______/______/______Month Day Year Month Day Year</p><p>Informant: ______Relationship To Child: ______</p><p>What Made You Seek Help At This Time?: ______</p><p>Provide A Brief Description Of Major Areas Of Concern (Including duration and how you have handled them): ______</p><p>Has Your Child Had Any Previous Psychiatric/Psychological Evaluations/Treatments? (Please elaborate)</p><p>Date Treating Professional Reason Outcome ______Developmental Milestones (In months)</p><p>Sat alone: ______Walked: ______Talked in sentences: ______</p><p>Weaned: ______Fed self: ______Tied own shoes: ______</p><p>Toilet Training (Ease or difficulty; any wetting or soiling afterward): ______Who Does Your Child Live With/ Who Has Everyday Custody Of your Child?: ______</p><p>Academic History (Please provide grade level, name of the school and any pertinent school history): ______</p><p>Past And Current Medical History/Meds: ______</p><p>Please Comment On Any Areas Of Concern Not Covered Above: ______</p><p>______Signature of person completing form Date</p><p>______Clinician’s signature Date</p>