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FastBraiin HX Form
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Prenatal & Birth History
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Normal Pregnancy and prenatal care
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Please specify:
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Used drugs or alcohol during pregnancy
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Please specify:
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Used prescription or other medication
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Comments:
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Normal delivery:
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Comments:
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Breast Fed:
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How long:
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Developmental History
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Speaking in phrases by 18-24 months?
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Comments:
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Rolling over @ 2 months?
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Comments:
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Sitting up @ 6 months?
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Comments:
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Crawling @ 9 months?
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Comments:
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Walking @ 15 months?
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Comments:
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Receive ST. OT, or PT?
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Please specify:
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Diagnosed with LD or impairments?
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Comments:
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School History
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Concern of learning disability
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Comments:
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Problems with performance and testing
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Comments:
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IEP/504 Plan in Place:
• • •
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Comments:
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Psychological-educational testing completed
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Comments:
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Repeat a school level
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Comments:
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Detention, Suspension, ISS
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Comments:
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Family/Med HX
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Hospital HX
• • •
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Comments:
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Past Surgical HX
• • •
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Comments:
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Immunization Status
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Comments:
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Father HX
• • •
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Comments
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Mother's HX
• • •
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Comments
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Children(s)' HX
• • •
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Comments
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Sibling(s)' HX
• • •
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Comments
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Marital Status
• • •
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Comments
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Living Arrangements
• • •
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Comments
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