<p> Developmental and Behavioral Pediatrics History (Biological, Social, Behavioral)</p><p>Child’s Name ______Age______Grade ______DOB ______</p><p>Phone ______Physician ______School/Teacher ______</p><p>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.</p><p>A. Current and Past Concerns</p><p>What are your primary concerns for your child? (Please include any previous diagnoses.) </p><p>______</p><p>______</p><p>______</p><p>B. Birth History</p><p>1. Prenatal Complications: ______</p><p>______</p><p>______</p><p>A. Was your child unusually active during the pregnancy? ______</p><p>B. Was this pregnancy different from your others? ______</p><p>2. During or shortly before pregnancy, Maternal history was:</p><p>A. Medications: ______</p><p>B. Substance Use: Cigarettes ______Alcohol ______Drugs ______</p><p>C. Major Life Stress: ______</p><p>D. Medical Problems: ______</p><p>E. Surgeries: ______C. Medical History</p><p>1. Just after birth (neonatal) history: ______</p><p>A. Birth Weight ______B. Birth length______</p><p>C. APGAR Score ______D. Complications ______</p><p>2. Was the child born more than three weeks early or late? Yes ______No ______</p><p>3. Current health status? Good ______Not Good ______</p><p>Please explain: ______</p><p>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? ______</p><p>4. Family Health/Mental Health History (Please review the health history of close family members: parents, grandparents, aunts, uncles, sisters, brothers, cousins).</p><p>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? ______</p><p>D. Developmental History</p><p>1. When did you first become concerned about your child’s development? ______</p><p>______2. What happened that made you become concerned? ______</p><p>______</p><p>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? ______</p><p>4. Which hand does your child prefer? Right ______Left ______Both ______</p><p>5. In comparison to other children his/her age, does your child seem awkward in physical activities (example: running, jumping, cutting paper, writing, etc.)? ______</p><p>If so, please specify and explain. ______</p><p>______</p><p>______</p><p>6. Describe your child’s ability to develop habits and consistent behaviors: A. Eating ______B. Sleeping ______C. Toileting ______</p><p>7. Describe your child’s temperament, “general approach to the world”. For example: easy going, irritable, happy, flexible, etc. ______</p><p>______</p><p>______</p><p>8. Does your child remind you of any other family members? ______</p><p>Please explain: ______</p><p>9. Is your child’s development: A. Moving forward ______B. Stable ______C. Declining ______E. Family History and Home Environment</p><p>1. Household Information:</p><p>Family Members Lives With Child Family Members School Birthday Yes No or Health Problems</p><p>Father ______Mother______Guardian ______Brothers’ ______(In order of age) Sisters’______(In order of age) Others ______</p><p>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? ______</p><p>3. Do family members get along? ______</p><p>4. How would you describe your home? VERY ORGANIZED ______AVERAGE ______DISORGANIZED ______5. How would you describe your discipline standards? STRICT ______MODERATE ______PERMISSIVE ______</p><p>6. How would you describe your discipline style? CONSISTENT ______INCONSISTENT ______</p><p>F. Educational History</p><p>1. Current Grade ______School ______Teacher ______</p><p>2. Academic difficulty was first noted in ______grade.</p><p>3. A grade was repeated in ______</p><p>4. Areas of academic strength are: ______</p><p>5. Areas of academic weakness are: ______</p><p>6. Current special education classification is: ______</p><p>7. Accommodations to regular education are: ______</p><p>8. Special education support services are: ______</p><p>9. Is your child liked by his/her teachers? ______</p><p>10. School and classroom behavior is: ______</p><p>G. Social Adjustments</p><p>1. Does your child get along well with: Brothers/sisters? ______Children his/her own age? ______Older children? ______Younger children? ______Adults? ______</p><p>2. Does your child prefer to play alone or with other children? ______</p><p>3. Does he/she often get into fights with other children? ______</p><p>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? ______</p><p>7. Is your child affectionate? ______</p><p>8. How does your child respond to affection? ______</p><p>9. Does the child insist on getting his/her own way? ______</p><p>10. Does he/she throw temper tantrums? ______If so, when? ______</p><p>11. Is your child shy? ______Does your child talk a lot? ______</p><p>12. Does your child daydream frequently? ______If so, what are they about? ______</p><p>13. Does he/she seem happy (laugh and smile much)? ______</p><p>14. Describe his/her favorite hobbies or interests. ______</p><p>15. What does your child do best? ______</p><p>16. What doe he/she most enjoy doing? ______</p><p>17. Is the child very active? ______Is the child sluggish? ______</p><p>18. Describe your child’s ability to follow the rules. ______</p><p>19. Describe your child’s ability to think before taking action. ______</p><p>20. Describe you child’s ability to wait for pleasurable events/objects. ______</p><p>21. Does your child generally feel lonely or different? ______</p><p>22. Behavior in the neighborhood is generally positive or negative, please explain. ______</p><p>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. ______</p><p>26. It is/is not hard for my child to resist distraction. ______</p><p>27. How would you describe your child in general? ______</p><p>Add Additional Information That You Feel Will Be Helpful In Evaluating Your Child</p><p>______</p>