DEVELOPMENTAL HISTORY FORM


       CHILD’S NAME_____________________________________________________

       DATE OF BIRTH_______________

       PERSONAL HISTORY:

       TYPE OF BIRTH_______________________________________

       ANY COMPLICATIONS?______________________

       AGE BEGAN SITTING_____________

      CRAWLING_____________

      WALKING_____________

      TALKING___________

      ANY SPEECH DIFFICULTIES?_____________________________

      SECOND LANGUAGE?_____________________

      HEALTH:

     ANY SERIOUS ILLNESS OR HOSPITALIZATION?________________________________________________

     ANY DISABILITIES?_________________________________________________

     IS YOUR CHILD ON REGULAR MEDICATION?____________________

     IF SO WHAT_________________________

     EATING:

     DOES YOUR CHILD HAVE ANY EATING PROBLEMS?

     _________________________________________________

     ANY FOOD ALLERGIES?

     ____________________________________________________________________________________

     FAVORITE FOODS

     ____________________________________________________________________________________

    TOILET HABITS:

    CAN YOUR CHILD INDICATE BATHROOM NEEDS?______________________________________________________

    WORD FOR URINATION_________________________

    WORD FOR BOWEL MOVEMENT____________________

    DOES YOUR CHILD HAVE FREQUENT “ACCIDENTS”? ___________

    IS YOUR CHILD WEARING DIAPERS OR “PULL-UPS”?____________

    SLEEPING HABITS:

    DOES YOUR CHILD NAP DAILY?_____________

    IF SO, WHEN?________________


    DO YOU PREFER THAT YOUR CHILD NAP AT SCHOOL OR IS A QUIET TIME OKAY?______________

    SOCIAL RELATIONSHIPS:

    DOES YOUR CHILD PLAY WITH PEERS IN YOUR NEIGHBORHOOD?____________________
   
    IS YOUR CHILD:

    AGGRESSIVE/PHYSICAL?_______________

    QUIET/SHY?_______________

    HAPPY/CONTENT?_______________

    DO YOU ANTICIPATE SEPARATION PROBLEMS WHEN YOUR CHILD BEGINS SCHOOL?___________________

    HOW DO YOU DISCIPLINE YOUR CHILD AT HOME?_________________________________________________

    WHAT IS YOUR CHILD’S FAVORITE ACTIVITIES?_________________________________________________

    PARENT SIGNATURE_________________________________________

    DATE________/________/__________