Child History Parents Child History_Parents X/TwitterThis field is for validation purposes and should be left unchanged.Child Information and HistoryChild's NameDate MM slash DD slash YYYY Parent/Guardian Tel: (home)Parent/Guardian Tel: (work)AgeBirthdate MM slash DD slash YYYY Religion ( optional)SexEthnic or racial backgroundGrade and schoolHand child uses for writing or drawing: Right Left Switches between them Primary languageSecondary languagePrevious diagnosis (1)If any (2)Who referred the child to our office?Briefly describe the problem:What specific concerns do you have?THIS FORM HAS BEEN COMPLETED BY:NameRelationship to childAddressPhone (H)(W)SYMPTOM SURVEY For each symptom that applies to the child, place a check. Compare the child to other children of the same age. Add any helpful comments next to the item.1) PROBLEM SOLVING Difficulty figuring out how to do new things Difficulty making decisions Difficulty planning ahead Difficulty solving problems a younger child can do Disorganized in his/her approach to problems Difficulty understanding explanations Difficulty doing things in the right order (sequencing) Difficulty verbally describing the steps involved in doing something Difficulty changing a plan or activity in a reasonable period of time Is slow to learn new things Difficulty switching from one activity to another activity Easily frustrated Other problem solving difficulties Explain2) SPEECH, LANGUAGE, AND MATH SKILLS Difficulty speaking clearly Difficulty finding the right word to say Not talking Rambles on and on without saying much Jumps from topic to topic Odd or unusual language or vocal sounds Difficulty understanding what others are saying Difficulty in writing letters or words Difficulty reading letters or words Difficulty with spelling Difficulty with math Other speech, language, or math problems: Explain3) SPATIAL SKILLS Confusion telling right from left Has difficulty with puzzles, Legos, blocks, or similar games Problems drawing or copying Doesn't know his/her colors Difficulty dressing (not due to physical difficulty) Problems finding his/her way around places he/she has been before Difficulty recognizing objects Seems unable to recognize facial or body expressions of disapproval or emotions Gets lost easily Other spatial problems Explain4) AWARENESS AND CONCENTRATION Easily distracted by Sounds Easily distracted by Sights Easily distracted by Physical sensations Mind appears to go blank at times Loses train of thought Difficulty concentrating on what others say, but can sit in front of a TV for long periods Attention starts out OK but can't keep it up Other attention or concentration problems: Explain5) MEMORY Forgets where he/she leaves things Forgets things that happened recently (e.g., last meal) Forgets things that happened days/weeks ago Forgets what he/she is supposed to be doing Forgets names more than most people do Forgets school assignments Forgets instructions □ Other memory problems: Explain6) MOTOR AND COORDINATION Check the side this occurs on:Poor fine motor skills (e.g., using a pencil or crayon) Right side Left side Both sides Clumsy Right side Left side Both sides Weakness Right side Left side Both sides Tremor Right side Left side Both sides Muscles are tight or spastic Right side Left side Both sides Odd movements (posturing, peculiar hand movements, etc.) Right side Left side Both sides Drops things more than most children Right side Left side Both sides Has an unusual walk Right side Left side Both sides Balance problems Right side Left side Both sides Other motor or coordination problems:7) SENSORY Check the side this occurs on:Needs to squint or move closer to page to read Right side Left side Both sides Problems seeing objects Right side Left side Both sides Sensory Loss of feeling Problems hearing sounds Difficulty telling hot from cold Difficulty smelling odors Difficulty tasting food Overly sensitive to: Touch Overly sensitive to: Light Overly sensitive to: Noise Other sensory problems: Other sensory problems8) PHYSICAL Frequently complains of headaches or nausea Had dizzy spells Has pains in joints Excessive tiredness Frequent urination or drinking Other physical problems: How Often?Where?Other9) BEHAVIOR Aggressive Nervous Attached to things, not people Nightmares, night terrors, sleepwalks Bedwetting Quiet Bizarre Behavior Resists Change Bowel movement in underwear Risk-taking Dependent Self-mutilates Depressed Self-stimulates Eating habits are poor Shy and withdrawn Emotional Sleeping habits are poor Fearful Swears a lot Immature Unmotivated Other unusual behavior: OtherBelow check all the descriptions of the child that have been present for at least the past 6 months. These behaviors should occur more frequently than in other children of the same age. Is very fidgety Steals things without people knowing on several occasions Can't remain seated Often runs away from his parents' home and stays away overnight Highly distractible Easily lies to others Can't wait for his/her turn when playing with others Firesetting Answers before he/she hears the whole question Doesn't go to school Rarely follows others' instructions Breaks into other people's property Has a hard time concentrating for long periods Destroys other people's property in some manner other than by fire Goes from one activity to another without finishing anything Seems like he/she is always talking Frequently makes noise when playing Is cruel to animals Is often rude or interrupts others Has forcible sexual relations with others Doesn't listen to other people Starts fights with others Seems like he/she frequently is losing things that are needed for school Will steal directly from people When fighting, has used a weapon on more than one occasion Is cruel to other people Frequently does dangerous things without considering consequences 10) Overall, the child's symptoms have developed: Slowly Quickly 11) The symptoms occur: Occasionally Often 12) Over the past 6 months the symptoms have: Stayed about the same Worsened PREGNANCY13) Mother's age at child's birth:Father's age at child's birth:14) Before the pregnancy, what medications (prescribed or over-the-counter) did the mother take? List all medications used: Add Remove15) While pregnant, what medications (prescribed or over-the-counter) did the mother take? List all medications used: Add Remove16) How often did the mother see her doctor during the pregnancy? Regularly (as scheduled by the doctor) Rarely Not at all 17) During the pregnancy, which of the following did the mother use? Alcohol Caffeine Marijuana Recreational drugs (cocaine, heroin, etc.) Tobacco Amount and Daily Frequency18) During the pregnancy, the mother's diet was: Good Poor If poor, explain:19) The mother's general physical health during the pregnancy was: Good Poor If poor, explain:20) About how much weight did the mother gain while she was pregnant? (lbs)21) During this pregnancy, check all the mother had: Accident Anemia Bleeding (severe or frequent spotting) Diabetes High blood pressure Pelvic irradiation Preeclampsia, eclampsia, or toxemia Psychological problems Surgery Vomiting (severe or frequent) 22) How many pregnancies did the mother have prior to this one? Number of live births: Number of miscarriages: BIRTH23) Was this child born: Early On time (38-42 weeks) Late How early? (weeks)How late? (weeks)24) How much did the baby weigh at birth? (mention lbs., oz, or gms.)25) How long did the labor last?26) The labor was: Easy Moderately difficult Very difficult 27) What type of medication was the mother given to help with the delivery? None Demerol Gas Regional nerve (spinal block) Tranquilizer Epidural 28) Were forceps used during delivery? Yes No 29) Was the baby born: Head first Transverse (crosswise) Posterior first Breech birth Caesarean section Vacuum extraction Other Other30) Did the baby experience any of these problems: Fetal distress Low placenta (Placenta previa) Prolapsed cord Premature separation of placenta (Abrupto placenta) Cord wrapped around neck 31) Describe any other special problems the mother or child had during delivery:32) At birth, did the baby: Have difficulty breathing? Yes No Fail to cry? Yes No Appear inactive? Yes No 33) List the baby's Apgar scores:1st2nd34) If the father or the mother noticed anything unusual when they first saw the baby, describe: If the baby was born with any problems (congenital defects, large or small head, blue baby, bleeding in brain, etc, describe:Describe any special problems that the baby had in the first few days following birth:Describe any special care, treatment, or equipment the child was given after birth:How long did the baby stay in the hospital?DEVELOPMENTAL HISTORY 35)For each area, indicate the child's development by circling one description. The "average" period is only a rough idea of what is average since every developmental milestone actually involves a range of several months ( e.g. walking occurs approximately 9-18 months of age). Circle "early" or "late" only if you are sure the child's development was different from that of most other children.GROSS MOTOR SKILLS Crawled Early Average (6-9 mos) Late Walked alone (2-3 steps) Early Average (9-18 mos) Late LANGUAGEFollowed simple commands Early Average (12-18 mos) Late Used single-word sentences Early Average (12-24 mos) Late SELF-HELPToilet trained Early Average (13-36 mos) Late 36) List any other significant developmental problems:37) Overall, the child's development was: Early Average Late 38) As an infant or toddler, did the child have poor muscle control (i.e. weakness) of the: Neck Trunk Legs Arms 39) As an infant or toddler, did the child's muscles seem to be unusually tight or stiff? Yes No If yes, describe:40) Toilet training was: Easy Difficult 41) As an infant or toddler, the child was: Too calm and inactive Calm and reasonably active Irritable and very active 42) As a toddler, the child was: Shy and inhibited Neither shy nor outgoing Very outgoing and liked people 43) Did the child have a poor appetite as a baby? Yes No 44) Did the child fail to gain weight steadily as a baby? Yes No 45) List the baby's illnesses or physical problems during the first year:46) Has the child had a temperature of I 04 °F ( 40°C) or higher for more than a few hours? Yes No If yes, what age (s)?and how long did it last?47) Has the child ever been hit hard on the head or suffered a head injury? Yes No If yes, what age (s)?Did the child lose consciousness? Yes No How did it happen?What problems did the child have (physical or mental) afterwards?48) Has the child been diagnosed with seizures or epilepsy? Yes No If yes, which type? Partial seizure Generalized seizure Unclassified type If medication is used, which medication(s)?Has the child ever had a bad reaction to this medication? Yes No If yes, describe:Did the child ever have a seizure due to a fever or unknown cause? Yes No If yes, describe (age, nature of seizure):49) Was the child ever in the hospital for an accident, injury or operation? Yes No If yes, what age(s)?What happened?50) Has the child ever swallowed any poison, non-food, or drug accidentally? Yes No If yes, what age(s)?What happened?51) Did the child have frequent ear infections? Yes No If yes, what age(s)?How often and severe?What treatment was provided?52) Please check all the following diseases or conditions the child has ever had: Allergies Cerebral palsy Jaundice Mumps Anemia Chicken pox Kidney disorder Oxygen deprivation Asthma Colds (excessive) Leukemia Pneumonia Bleeding disorder Diabetes Liver disorder Rheumatic fever Blood disorder Encephalitis Lung disorder Scarlet fever Brain disorder Enzyme deficiency Measles Tuberculosis Broken bones Genetic disorder Meningitis Venereal disease Cancer Heart disorder Metabolic disorder Whooping cough Other problems: Other problems:53) As the child has been growing up, he/she has been sick: Much of the time An average amount Not much at all 54) List all the medications the child takes now:MedicationDosageHow often?What for? Add Remove55) Does the child: Wear glasses? Yes No Glasses for? Farsighted Nearsighted Other Use a hearing aid? Yes No 56) Within the past year, has the child had: A vision test? Yes No A hearing test? Yes No Results57) What is the child's Height (ft. and in.)Weight (lbs.)58) When was the child's last medical check-up?59) What therapies have been provided to the child? No therapies Occupational therapy Physical therapy Psychological therapy, counseling, or cognitive rehabilitation Speech therapy Other therapy: ExplainFAMILY HISTORY60) The child lives with: Biological parent(s) only Relatives Foster parents Biological parent and other Adoptive parents Institutional care Other placement: Other placement:61) The family's income is: under $10,000 $10,000-$29,999 $30,000-$50,000 over $50,000 62) What is the name of the child's biological mother?a. Is she living? Yes No If deceased, explain:b. Her age?c. What is her level of education?d. Her occupation?e. Does she live in the same house as the child? Yes No f. How often does she see the child?g. How involved is the mother in the child's upbringing? Very Somewhat Not at all h. Did the mother have a learning disability or other problems when she was in school? Yes No If yes, describe:i. What are the mother's hobbies?63)What is the name of the child's biological father?a. Is he living? Yes No If deceased, explain:b. His age?c. What is his level of education?d. His occupation?e. Does he live in the same house as the child? Yes No f. How often does he see the child?g. How involved is the father in the child's upbringing? Very Somewhat Not at all h. Did the father have a learning disability or other problems when she was in school? Yes No If yes, describe:i. What are the father's hobbies?64) Please list the names, ages, and grade ( or job) of the child's brothers and sister:NameAgeGrade or job Add Remove65) Has anyone in the child's biological family (including parents, grandparents, siblings, aunts & uncles) ever had any of the following: Brain disease Developmental delay Epilepsy or seizures Learning disability Intellectual Disabilities Neurological disease Psychological problems Reading or spelling difficulties Speech or language problems Which relative?Describe the problem briefly66)Which of the child's biological relatives are left handed? No one Mother Father Sibling(s) Grandparent(s) 67) What languages are spoken in the home? (list in order of the most frequent first)1268) How is the child disciplined?69) List the child's usual recreational activities and hobbies:70) Have there been any major family stresses or changes in the past year ( e.g. moving with change of school, divorce, significant illness, etc)? Yes No If yes, explain:How much stress have these changes caused the child? (choose one) None Mild Moderate Severe SCHOOL HISTORY71) The child's present school is: Name:Address:Phone:Contact person:72) Was the child ever held back to repeat a grade? Yes No If yes, which grade?Why?73) Has the child ever been in a special class or provided with special services ( e.g. resource room, EMR, learning disability class, etc.)? Yes No If yes, describe the special class:Is the child in this class or receiving special services now? Yes No 74) Does the child like school? Most of the time Some of the time Almost never 75) Does the child:Have problems with other children in class? Yes No Have problems making friends in school? Yes No Have problems getting along with teachers? Yes No Tend to get sick in the morning before school? Yes No 76) Describe the teacher's concerns about the child's schoolwork or behavior:77) What kind of grades has the child received in the past year? A's & B's B's & C's C's & D's D's & F's or Outstanding Good Satisfactory Improvement needed Unsatisfactory or Other grading system: or Other grading system:Are these grades a change from previous years? Yes No 78) In which subject(s) does the child do best?79) Which subject(s) are the most difficult?80) In the past year, how much school has the child missed due to illness or injury? Less than 2 weeks 2 to 4 weeks 5 to 8 weeks Over 8 weeks Briefly describe the reasons if the child has missed a lot of school:81) Does the child seem to have a "school phobia"? Yes No If yes, explain:PREVIOUS EVALUATIONS 82) Which of these tests or procedures have been done recently? Note any abnormal findings.Evaluation:Check here if normal Blood work Family physician or pediatrician office visit Hearing testing Lead level check Lumbar puncture or spinal tap Neurological exam or testing Psychological or neuropsychological testing School testing Speech & language testing Vision testing X-rays Other tests: Other testsAbnormal findings83) What are the names of the physician, psychologist, school authority, or other professionals we may contact who are most familiar with the child's problems?Name:Address Street Address City State / Province / Region ZIP / Postal Code Phone:Profession:Name:Address Street Address City State / Province / Region ZIP / Postal Code Phone:Profession:Parent of Guardian's signatureDate MM slash DD slash YYYY THANK YOU FOR TAKING THE TIME TO CAREFULLY COMPLETE THIS QUESTIONNAIRE
