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HIPAA- Developmental History
Office Location
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Please select your correct location for each form.
Lakeland
Brandon
Child's First Name
*
Child's Last Name
*
Date of Birth
*
Month
Day
Year
Parent/Guardian Full Name
Email
*
Date
*
Month
Day
Year
General Information
What is it about your child's development or medical condition that concerns you?
When was it first noticed?
Does your child become impatient or frustrated?
Describe any changes in your child's development within the past three months:
Describe your child's strengths:
Describe your child's weaknesses:
What are your goals for your child?
Medical History
History of Pregnancy
Were there any problems with the pregnancy with this child (RH incompatibility, toxemia, drug/alcohol abuse, exposure to infections/illness, unusual stress, etc.)?
Mother's age at delivery:
Number of previous miscarriages:
Labor and Delivery
Full Term?
Yes
No
If no, how early?
How late:
Birth weight:
Weight at discharge:
Apgar Scores:
Were there complications during delivery/labor? Please describe:
Check all that apply:
Cesarean Section
Transverse (sideways)
Required a birth monitor
Respirator
Jaundiced
Require exchange transfusion
Breech
Transfusion
Seizures
Birth Injuries
Cried right away
Face presentation
Cord around neck
Required forceps
Feeding difficulties
Infections
Heart defect
Was your child in a regular or special care nursery?
How long?
Age at discharge?
How was your child fed during hospitalization?
How is your child fed now?
List any congenital abnormalities:
Describe disposition/temperament (colic, sleep patterns, acceptance of being held):
Medical History of Child
Childhood Diseases (check all that apply):
Chicken Pox
Roseola
Measles
Scarlet Fever
Mumps
Whooping Cough
Any unusual problems:
Other Childhood Problems (check all that apply):
Allergies
Growth/weight problems
Meningitis/encephalitis
Recurrent ear infection/tubes
Urine/bowel problems
Vision problems
Asthma
Headaches/dizziness
Persistent drooling
Recurrent colds
Seizures
Hearing problems
Feeding problems
High fevers
Persistent vomiting
Pneumonia
Sinusitis
Clumsiness
Other:
Developmental History
The approximate age your child achieved the following developmental milestones:
Sat alone:
Crawled:
Hand preference:
Walked:
Toilet Trained:
Speech-Language Development (check all that apply):
Did/does your child:
Coo, babble, vocal play
Imitate sounds, words or phrases
Play peek-a-boo, pat-a-cake
Imitate gestures (wave bye-bye, "so big")
Use single works by 12-18 months
Understand what you are saying
Retrieve/point to common objects upon request
Follow simple directions (shut the door)
Respond appropriately to yes/no questions
Gross Motor Development (check all that apply):
Did/does your child:
Lift head while on stomach
Roll over
Sit alone
Creep on hands and knees
Throw ball overhand
Balance on each foot
Bear weight on legs
Pull self on tummy
Standing holding on
Stand alone
Run
Jump
Bear weight on arms
Pull to sit
Pull to stand
Walk
Walk up steps
Walk backward
Fine Motor Development (check all that apply):
Did/does your child:
Follow with eyes to center
Hold rattle
Reach for objects
Hold object with thumb & finger
Build tower with blocks
Cut on a line/around a shape
Tie shoes
Follow with eyes past center
Bring hands together
Transfer objects from hand to hand
Scribble
Copy shapes
Open/close buttons
Open/close zippers
Sensory- Did/does your child:
Have trouble falling asleep
Engage in self-stimulatory behaviors
React negatively to "normal" noises
Fear of climbing
Fall frequently
Dislike certain temperatures
Avoid being touched
Hear things most people tune out
Refuse to wear certain clothing pieces/textures
Is always in motion
Dislike certain tastes
Dislike certain textures
Family Information
Does your child interact with other children on a regular basis? (siblings, daycare, school, babysitter, play group)
Behavior patterns (check all that apply):
Interacts well with children/adults
Cooperative
Imitates actions/gestures/speech
Easily distracted/short attention
Withdrawn
Dislike certain temperatures
Destructive
Can play alone for reasonable length of time
Attentive
Tries new activities
Separation difficulties
Easily frustrated/agitated
Poor eye contact
Aggressive
Withdrawn
Inappropriate behaviors
If yes to inappropriate behaviors, please list:
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