DEVELOPMENTAL HISTORY QUESTIONNAIRE

Children & Adolescents

Name of Child: ______________________________ todays Date: ______________
Childs Birth date: ___________________________________ AGE: ______________
Current School: ___________________________________ Grade: _______________
Describe the problem or desired outcome for therapy or assessment:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________
Genogram:

PRENATAL HISTORY
How childs/ adolescents mothers health during pregnancy?
Good ____Fair _____Poor _____ DK _____
Did childs/ adolescents mother have any illness or complications during pregnancy with this child?
What type?
How old were childs/ adolescents mother when (s) he was born? _________
Any drugs or medications being used during pregnancy?______
(Please specify) _________________
Was there toxemia or eclampsia? No ___ Yes ___ DK ___
Was there an Rh factor incompatibility? No ___ Yes ___ DK ___

Developmental History Questionnaire

Was the pregnancy planned or unplanned? Wanted or unwanted?

Was there anything unusual about the delivery or birth?
Was (s) he born on schedule? If not how early or late?
What was the duration of labor?
Were childs/ adolescents mother given any drugs to ease the pain during labor?
Name: ______________________________________
Were there any signs of fetal distress during labor or birth? _______________
Was the delivery:
(Normal, Breech, Caesarian, Forceps, Induced)
What was the child's birth weight?__________________________
Were there any health complications following birth? Please describe:
____________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________

POSTNATAL PERIOD AND INFANCY

Were there early infancy problems/difficulties? (Feeding, colic, sleep pattern, infant's alertness) Please describe.
____________________________________________________________________________________
__________________________________________________________________________________
Was the child an easy baby? By that I mean did (s) he cries a lot? Did (s) he follow a schedule fairly
well?
________________________________________________________________________
Did the child experience any health problems during infancy? What type?
________________________________________________________________________
Did the child have any congenital problems? Please describe.
________________________________________________________________________
How did the baby behave with other people?

Developmental History Questionnaire

3
________________________________________________________________________
When (s) he wanted something, how insistent was (s) he?
________________________________________________________________________
How would you rate the activity level of the child as an infant / toddler?
________________________________________________________________________
DEVELOPMENTAL MILESTONES
At what age did (s) he: sit up: ______ crawl: ______ walk: ______
Speak single words (other than mama or dada)? _____ (s) he string two or more words together? _____
At what age was (s) he toilet trained (bladder control)? _____(bowel control)? _____
CURRENT STATUS:
How would you describe his/her health?
How is his/her: hearing: ______ vision: ______
Gross motor coordination (large muscle development walking, running, jumping):
Fine motor coordination (small muscle development finger/hand)?
Speech articulation (speech and language development)?
Has (s) he had any chronic health problems (e.g., asthma, diabetes, heart condition)?
If yes, please specify:
________________________________________________________________________
Which illnesses have the child/adolescent had?
(Specify)
________________________________________________________________________
Has (s) he had any accidents? _______
(Specify) How many accidents? Please give age or date of injury.
________________________________________________________________________
Is there any suspicion of alcohol or drug use? _____
Is there any history of physical/sexual abuse?_____

Developmental History Questionnaire

Does (s) he have any problems sleeping? ________

Does (s) he have bladder control or bowel control problems at night? _______
Does (s) he have any appetite control problems? _______
Please indicate if the child has been prescribed of any medicines recently? (Specify)
________________________________________________________________________
Has (s) he ever had any forms of psychological treatment? If so, please elaborate:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________
Is there any self-care, feeding, dressing or grooming concerns?
____________________________________________________________________________________
____________________________________________________________
Have any stress events occurred within the past 12 months?
(Please specify)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________
How is child/adolescent parents relationship? (Describe) family relationship? Father/child, mother/child
(Describe)
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________
SCHOOL HISTORY
GRADE:
________
SCHOOL:
___________________________

____________________________________TEACHERS

NAME:

SCHOOL COUNSELOR (if any) (: ____________________________________ NUMBER OF SCHOOLS ATTENDED?

_______

Developmental History Questionnaire

5
Please summarize the general school progress (e.g., academic, social, testing) within each grade levels.
Please describe strengths as well as problem areas or weaknesses in cognitive/academic skills and
behavioral control.
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
___________________________________________________________________________________
Has the (s) he ever been in any type of special educational program, and, if so, how long? Why?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________
Has the (s) he ever been? Suspended from school, expelled from school or retained in grade (Please
describe reasons and give brief details):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
________________________________________________________________________________
SOCIAL HISTORY
How does (s) he get along with his/her brothers/sisters? With peers? Keep friendships?
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
SYMPTOMS & BEHAVIORS OBSERVED:
What is considered to be a significant problem at the present time? (Describe symptoms)
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
___________________________________________________________________________________
When did these problems begin? (Specify age)________

Developmental History Questionnaire