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School/District:
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Phone#:
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Grade:
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Parent Email Address
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Parent A (select one)
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Parent Name:
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Date of birth
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Home Phone
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Work Phone:
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Cell Phone
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Address (if different than child/patient)
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Employed: (select one)
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Occupation
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Highest Level of Education
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Marital Status
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Sex
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Learning, Attention or Emotional problems? Please describe.
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Parent B (select one)
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Parent Name:
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Date of birth
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Home Phone
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Work Phone:
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Cell Phone
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Address (if different than child/patient)
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Employed: (select one)
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Occupation
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Highest Level of Education
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Marital Status
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Sex
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Learning, Attention or Emotional problems? Please describe.
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Referral Information
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Who referred you to our services?
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Why are you seeking help for this child?
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Primary Care Physician: (Please enter physician name not the practice name)
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PCP Address (Street address, city, state & zip)
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PCP Phone#:
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What is the primary language spoken at home?
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Secondary language(s)?
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Name of person completing this form:
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Relationship to this child:
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With whom does the child live with?
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How long in current living situation?
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Preferred Contact Person:
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Has your child ever experienced any parental separations, divorces or deaths?
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If 'yes', how old was your child at the time and please describe the circumstances:
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If parents divorced or separated, tap the switch in this box for additional questions
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Is there a custody agreement?
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If parents are separated or divorced, who has primary custody of your child?
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How often does your child see the non-custodial parent?
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Who cares for this child when the caregivers are gone?
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How many different people care for this child?
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How many hours per day is the child in a child-care setting?
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Please explain:
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Siblings and Relatives - Please list all siblings and all other persons living with the family.
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1 - Name
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Age
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Relationship to Child
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Living at home?
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Learning Problems?
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Emotional Problems
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Developmental Disabilities
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Date of Birth
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2 - Name
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Age
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Relationship to Child
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Living at home?
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Learning Problems?
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Emotional Problems
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Developmental Disabilities
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Date of Birth
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3 - Name
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Age
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Relationship to Child
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Living at home?
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Learning Problems?
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Emotional Problems
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Developmental Disabilities
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Date of Birth
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4 - Name
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Age
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Relationship to Child
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Living at home?
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Learning Problems?
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Emotional Problems
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Developmental Disabilities
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Date of Birth
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5 - Name
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Age
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Relationship to Child
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Living at home?
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Learning Problems?
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Emotional Problems
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Developmental Disabilities
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Date of Birth
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Please list any other Family members with a history of learning or developmental disorders, attention or psych problems:
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Is there a family history of Cardiac Disease earlier than 35 years old?
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Mother's Prenatal History
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Was the mother under a doctor's care?
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Number of previous pregnancies/miscarriages:
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Select any of the following complications that occurred during pregnancy:
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Other Illness (describe):
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Maternal Injury (describe):
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Hospitalization during pregnancy, reason:
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Medication taken during pregnancy (list one)
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Type of Medication (vitamin, supplement, over-the-counter, etc) / Frequency
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Medication taken during pregnancy (list one)
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Type of Medication (vitamin, supplement, over-the-counter, etc) / Frequency
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Medication taken during pregnancy (list one)
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Type of Medication (vitamin, supplement, over-the-counter, etc) / Frequency
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Medication taken during pregnancy (list one)
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Type of Medication (vitamin, supplement, over-the-counter, etc) / Frequency
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Medication taken during pregnancy (list one)
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Type of Medication (vitamin, supplement, over-the-counter, etc) / Frequency
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Cigarette use prior to pregnancy
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Alcohol usage prior to pregnancy (Frequency)
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Cigarette use during pregnancy
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Alcohol usage during pregnancy (Frequency)
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Drugs/subscances used during pregnancy (Frequency):
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Child's Birth
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Mother's Age at Birth
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Father's Age at Birth:
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Is this child a twin/multiple birth?
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If multiple birth, how many?
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What order of birth?
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State/County child was born in:
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Length of pregnancy (in weeks)
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Apgar Scores
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Birth Weight (lbs. & oz.)
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Child's Condition at birth
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Mother's Condition at birth
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Home Birth?
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Mother's hospital stay (in days)
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Child's hospital stay (in days)
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Name of Hospital
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Select any of the following complications that occurred during birth
• • •
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C-Section Reason:
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Incubator: length of treatment
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Bilirubin Lights: length of treatment
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Child's Medical History
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Gastrointestinal
• • •
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Musculoskeletal
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If Other:
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Respiratory
• • •
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Hearing
• • •
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Date of most recent Hearing Exam
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Vision
• • •
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Date of most recent Vision Exam
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Cardiovascular
• • •
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Neuro
• • •
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Allergies (Food, medication, etc)
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Skin
• • •
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Immunizations Current
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If "no", please explain reason:
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Medications - List all LONG-TERM medications this child has ever been on (include supplements & OTC):
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1 - Medication Name
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Age
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Dosage/Strength (ex. 10mg/5x daily)
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Treatment length (ex. 6 months, 1 year, etc)
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2 - Medication Name
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Age
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Dosage/Strength (ex. 10mg/5x daily)
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Treatment length (ex. 6 months, 1 year, etc)
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3 - Medication Name
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Age
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Dosage/Strength (ex. 10mg/5x daily)
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Treatment length (ex. 6 months, 1 year, etc)
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4 - Medication Name
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Age
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Dosage/Strength (ex. 10mg/5x daily)
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Treatment length (ex. 6 months, 1 year, etc)
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Developmental and Behavioral History
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At what age did your child sit alone?
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At what age did your child walk alone?
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At what age did your child pincer grasp?
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At what age did your child speak his/her first word?
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At what age did your child speak 2-3 word phrases?
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At what age did your child button/Zipper/snap?
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At what age did your child ride a bike with training wheels?
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At what age did your child ride a bike without training wheels?
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At what age did your child tie shoelaces?
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Which hand does your child use for writing or drawing
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Which hand does your child use for eating?
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Which hand does your child use for other actions (throwing, etc)?
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Has your child been forced to change writing hand?
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Which foot does your child kick with?
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Does your child have poor handwriting?
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Does your child have Speech/Language defects?
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How old was your child when toilet trained for Daytime Urine?
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How old was your child when toilet trained for Nighttime Urine?
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How old was your child when toilet trained for Daytime Stool?
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How old was your child when toilet trained for Nighttime Stool?
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What do you enjoy most about this child?
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What do you find most difficult about raising this child?
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What makes your child angry?
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How old do you think your child acts?
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Please describe discipline techniques:
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Describe your child's activity level
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Does your child have mood swings?
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If Yes, how often?
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Does your child exhibit any of the following behaviors? (Please select all that apply)
• • •
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Please list any CURRENT MEDICATIONS prescribed or OTC/supplements
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1-Medication
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Dosage/Strength (ex. 10mg/5x daily)
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Frequency
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2-Medication
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Dosage/Strength (ex. 10mg/5x daily)
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Frequency
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3-Medication
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Dosage/Strength (ex. 10mg/5x daily)
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Frequency
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4-Medication
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Dosage/Strength (ex. 10mg/5x daily)
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Frequency
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