Developmental History Form – Pediatric Therapy Services

Office Location*

Please select your correct location for each form.

Child's First Name*

Child's Last Name*

Date of Birth*

Parent/Guardian Full Name

Email*

Date*

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:

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):

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:

Fine Motor Development (check all that apply):

Did/does your child:

Sensory- Did/does your child:

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):

If yes to inappropriate behaviors, please list:

HIPAA- Developmental History

General Information

Medical History

Developmental History

Speech-Language Development (check all that apply):

Gross Motor Development (check all that apply):

Fine Motor Development (check all that apply):

Family Information

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