MAJOR CONCERNS
At what age did you or others first have concerns about his development?
What were those concerns?
What are your current concerns?
What goals do you have for your visit today?
What would you like to accomplish?
What questions would you like answered?
PREVIOUS ASSESSMENTS
What was the first educational intervention? What age?
What other educational interventions has he had?
What current interventions are in place?
Does he receive occupational therapy? When did this begin? What specific techniques are used during
this therapy? How has he responded to it?
Does he receive physical therapy? When did this begin? What specific techniques are used during this
therapy? How has he responded to it?
Does he receive speech-language therapy? When did this begin? What specific techniques are used
during this therapy? How has he responded to it?
Have you tried any complementary or alternative interventions?
What psychological or neuropsychological testing has been done?
What did this testing show?
What is your understanding of the results of these tests?
What is your understanding of his diagnosis?
What is your understanding of the results of prior evaluations?
What medical testing has been done (EEG? MRI? Other?)
What schools has he attended?
What school does he attend currently?
What type of school is this?
Describe the classroom setting.
How many children are in the class? What is the teacher to student ratio? Does he have a one to one
aide?
Is he a client of California Children’s Services or the Regional Center?
What providers are currently involved in his care?
What learning techniques do you implement at home?
PAST MEDICAL HISTORY:
MEDICTIONS (including prescription, over the counter, dietary supplements, other substances):
ALLERGIES (including medication, food, other):
PRENATAL and BIRTH HISTORY:
How old was mom at the time of child’s birth?
How old was dad at the time of child’s birth?
How many pregnancies has mom had in total?
How many deliveries has mom had?
How many miscarriages has mom had?
How many therapeutic abortions has mom had?
Did mom take any prescription medications during pregnancy?
Did mom smoke cigarettes, drink alcohol, or take recreational drugs during pregnancy?
Was mom exposed to any known toxins during pregnancy?
Was the pregnancy planned?
Was there reproductive assistance (IVF, artificial insemination, etc.)?
Were there any complications with the pregnancy?
When during pregnancy did prenatal care begin?
What was the baby’s gestational age?
Was he delivered vaginally or by C-section?
Was there use of forceps or vacuum?
What were the Apgar scores?
Did the baby require cardiopulmonary resuscitation?
Were there any infections or other complications surrounding the time of birth?
Length of hospital stay?
Did mom have any health problems during the pregnancy?
DEVELOPMENTAL HISTORY (please include the AGE at which each milestone was achieved, at what AGE
the milestone was LOST if applicable, any specific concerns that parents had, and any EXAMPLES that
the parents can provide):
Language
MILESTONE
Coo
Babble
Understand “no”
1st word other
than mama or
dada
Speak in 2-word
phrases
Speak in 3-word
phrases
Speech fully
intelligible to
strangers
Sing songs
Tell tall tales
AGE milestone achieved
LOST?
EXAMPLES
CONCERNS
Non-verbal Communication
MILESTONE
AGE achieved
Wave “bye”
Indicate wants
Point to things he wants
Understand/respond to
others facial expressions
Notice or care how
others feel or react
Communicate by
nodding “yes” or shaking
“no”
Learn through imitation
MILESTONE
Fix on and track
faces
Smile in response
to others’ facial
expressions
Eye contact
Look to parents
(establish eye
contact) for
permission or
encouragement
Look to parents
(establish eye
contact) in
anticipation of
approval or
disapproval
LOST? EXAMPLES
CONCERNS
AGE milestone achieved
LOST?
EXAMPLES
CONCERNS
AGE milestone achieved
LOST?
EXAMPLES
CONCERNS
Play
MILESTONE
Parallel play (play
alongside other
children)
Interactive play
(play with other
children)
Imaginative play
(i.e. “play house,”
make up stories
during play)
Other types of
play
Peculiar play (i.e.
lining up toys,
preoccupation
with a particular
toy or part of a
toy)
Motor
MILESTONE
Sit on his own
Crawl
Walk
Run
Walk up stairs
Walk down stairs
Throw a ball
Kick a ball
Ride a tricycle
Ride bicycle
Reach for a toy
Feed himself
finger foods
Scribble with a
pencil
Tie shoes
Button a shirt
AGE milestone achieved
Repetitive or ritualistic behaviors
Does he have any repetitive movements
Does he have any unusual routines?
Does he have any tics?
Does he have hyperactivity?
Does he have inattention (difficulty focusing)?
Sensory
LOST?
EXAMPLES
CONCERNS
Does he have increased sensitivity to certain textures? Sensations? Sounds? Sights? Foods?
Does he have unusual liking of certain sensations? Sounds? Sights? Foods?
FAMILY HISTORY:
Consanguinity
Miscarriages
Sudden infant death
Children with difficulty walking
Children with difficulty talking
Children with difficulty
Seizure
Headache
Developmental delay
Mental retardation
Cerebral palsy
Learning disabilities
Autism
Tics
Movement disorder