JOSEPH J. ZIELINSKI, PH.D., ABPP, ABN, FICPP
New Jersey Licensed Psychologist 35SI 001300
1101 North Kings Highway, Suite #302
Cherry Hill, New Jersey 08034
(856) 438-5695
FAX (856) 438-5694
CHILD DEVELOPMENTAL HISTORY
Date:
Name of Child:
Date of Birth:
Age:
This questionnaire is to be filled out by a parent or responsible adult for the patient. Please try to answer all
questions, being as truthful and accurate as possible. You may use N/A for questions that are not applicable
or if answer is unknown.
Name of person completing this form:
1. About the pregnancy
Was this a planned pregnancy: Yes
No
If mother had any medical conditions during pregnancy, state condition/s, during what month of
pregnancy, type of treatment received, and how long condition lasted:
Was this a full term pregnancy: Yes
Length of active labor:
Type of delivery: Spontaneous
Was baby born: Head first:
Was it necessary to give baby oxygen: No:
Did baby require blood transfusions: Yes
Birth weight:
APGAR scores:
(9 mos.)
Yes:
No
Forceps
Feet First:
For how long:
No
at
Caesarian
Breech:
2. Child’s first two weeks of life
Did baby appear Jaundice
Nursing difficulty
Irritable/Colicky:
Very high fever
Blue lips
Convulsions/twitching
Slow in attaching/bonding
Licensed Psychologist
Certified School Psychologist
New Jersey & Pennsylvania
Did baby have vomiting
Birth Defects
Slow in responding
Neurological problems
Difficulty breathing
Slow in responding
Diplomate in Clinical Psychology
Board Certified Diplomate
American Board of Professional Psychology
Fellow in Psychopharmacology
Diplomate in Clinical Neuropsychology
Prescribing Psychologists’ Register
American Board of Professional Neuropsychology
months.
3. Later infancy
Normal weight gain: Yes
No
Percentile of weight gain from doctor:
Breast fed: No
Yes
Did baby feed well? Yes ( ) No ( ) If not, explain:
Vomiting, diarrhea, constipation, or colic No
Head banging
Thumb sucking
Why
How long
Yes
Teeth grinding
Explain:
Temper tantrums
4. At what age did child: (Check one)
First smile:
Less than 1 mo.
4-5 months
1-2 mos.
5-6 mos.
2-3 mos.
More than 6 mos.
3-4 mos.
6-9 mos.
18-24 mos.
9-12 mos.
24-30 mos.
12-15 mos.
30-36 mos.
5-9 mos.
18-21 mos.
9-12 mos.
21-24 mos.
12-15 mos.
More than 2 yrs.
9-12 mos.
21-24 mos.
12-15 mos.
More 2 years
15-18 mos.
12-15 mos.
More than 2 years
15-18 mos.
18-21 mos.
Doesn’t walk
6-9 mos.
18-24 mos.
9-12 mos.
More than 2 yrs.
12-15 mos.
Doesn’t speak
1-1½ yr.
More than 3 yrs.
1 1½-2yrs.
2yrs.-2½ yrs..
Doesn’t speak
Weaned from bottle:
Less than 6 mos.
15-18 months
First teeth:
0-5 mos.
15-18 mos.
Stand alone:
5-9 mos.
18-21 mos.
Walk alone:
Less than 12 mos.
21-24 mos.
First words:
Less than 6 mos.
15-18 mos.
First Sentences:
Less than 1 yr.
2½-3 yrs.
Toilet training:
12-15 mos.
30-36 mos.
15-18 mos.
18-24 mos.
Doesn’t stay dry thru day/night yet
24-30 mos.
5. Illnesses/diseases, injuries, emergency room visits and/or operations:
Please enter the date on the line when conditions were first noticed that pertain to your child.
Asthma
Eczema
Arthritis
Diabetes
Cancer
Anemia
Measles
Mumps
Chickenpox
Diphtheria
Scarlet fever
Polio
Cerebral Palsy
Encephalitis
Tuberculosis
Heart disease
Influenza
Pneumonia
Migraines
Undescended testicles
High or low blood pressure
Sinusitis
Heart surgery
Appendicitis
Tonsillectomy
Meningitis
Fainting/dizziness
Concussions
Convulsions
Note any other conditions not listed above:
Hospitalized
For What
How long in the hospital
Broken bones
Brain injury
Attending Physician
Age of child
6. If adolescent, at what age did the following changes occur:
Pubic hair
Menstruation
Voice change
Breast development
Hair on face
7. List any physical handicaps, disabilities or deformities:
Eyes:
Hearing:
Teeth
Height
Weight
Normal
Normal
Straight
ft.
lbs.
in.
Glasses:
Hearing Aids
Braces
Extractions
Percentile at pediatrician
Percentile at pediatrician
Cavities
8. Health of family (including parents, siblings, grandparents, aunts, uncles and
cousins). List any handicaps, operations or deaths. Examples could be cancer,
diabetes, epilepsy, heart disease, ADHD, Tourettes or Autism, schizophrenia,
bipolar illness or seizures.
Condition
Family Member
9. Main extracurricular activities
List any activities that your child participates in, and approximate number of hours per week involved. If
the activity requires a skill, please check whether the child is below average, average, or above average.
Some ideas of activities might be: climbing, fishing, video games, dating, stamp collecting, model
airplanes, sewing, dancing, musical instruments, reading, TV, any kind of sports, volunteer work, etc.
Activity
Hours per Week
Skill Level
10. Please add any additional information to help me understand your child better.