ABC Therapeutics
Developmental and Educational History Form
Child’s Name________________________Male_____Female_____ Date of Birth ____________
Address:____________________________City:___________Zip:_______ Phone: ___________
Mother’s Name:_____________________Occupation:____________ Work Phone:__________
Father’s Name:______________________Occupation:____________Work Phone: _________
Step-parent’s Name:__________________Occupation:____________Work Phone: _________
Child’s Home School: (School child will attend in Kindergarten)___________________________
Languages Spoken at Home:______________ Child’s Primary Language:_________________
Ethnicity:(circle one) White
Black
Hispanic
Native American
Asian
Other __________
Who is completing this form:________________________ Relationship to child:______________
What is your primary concern regarding your child’s development?________________________
_____________________________________________________________________________
_____________________________________________________________________________
Birth History
Child’s weight at birth ________ Was the baby full term?________ If not, how many weeks?____
Were there any complications during pregnancy? YES /NO Explain: (Ex. illness, injury, preterm
labor, etc.)
_____________________________________________________________________________
Were there any complications during birth? YES /NO Explain: (Ex. breech, instruments needed,
C-section)
_____________________________________________________________________________
Were there any complications after birth? YES /NO Explain: (Ex. jaundice, respiratory infections,
feeding difficulties)
_____________________________________________________________________________
Were there any other conditions present during or after birth that you feel were significant?
_____________________________________________________________________________
_____________________________________________________________________________
INFANCY PERIOD (Birth - 18 months) and TODDLER PERIOD (18 months - 3 Years)
Easy baby
Average baby
Difficult baby
Very active as infant and toddler
Average level of activity as infant and toddler
Not active as infant and toddler
Feeding problems
Enjoyed cuddling
Was not calmed by being held or stroked
Colicky
Sleep pattern difficulties and/or diminished sleep
Excessive restlessness
Problems with responsiveness and alertness
Head banging
Experienced health problems during this period of life
Had any congenital problems
Diagnosed as having the following disability or condition:
Constantly into everything
Excessive number of accidents compared to other children
More sociable than others
Average sociability
More unsociable than others
Very insistent when wanted something
Average insistent when wanted something
Not at all insistent when wanted something
Family History
Please list siblings and ages:
Name:__________________________ Age:___ Name:_________________________ Age:___
Name:__________________________ Age:___ Name:_________________________ Age:___
Name:__________________________ Age:___ Name:_________________________ Age:___
Who does child reside with including all members in the household? (Ex. siblings, step-parents,
grandparents, etc.)
_____________________________________________________________________________
_____________________________________________________________________________
Have any family members, including extended family experienced any of the following:
(Describe relationship to child)
Developmental Delays YES / NO Explain:____________________________________________
Speech and Language Problems YES / NO
Explain:_______________________________________________________________________
Learning Difficulties YES / NO Explain:______________________________________________
Medical History
Physician’s Name:____________________Phone:_________Date of last check-up?__________
How would you describe your child’s health?
EXCELLENT
GOOD
FAIR
POOR
Has your child had a history of the following:
Chronic Ear infections YES /NO How frequent?_____________Describe treatment:__________
Allergies YES /NO What is your child allergic to?______________ Treatment?_______________
Accidents YES /NO
Describe:__________________________________________________________
_____________________________________________________________________________
Chronic Colds YES /NO How often?
_____________________________________________________
Respiratory Illnesses? YES /NO Describe:
________________________________________________
High Fevers YES /NO How often? Explain:
________________________________________________
Seizures YES /NO
Explain:____________________________________________________________
Head Injuries YES /NO Explain:
________________________________________________________
Serious Illnesses YES /NO
Describe:____________________________________________________
Surgeries YES /NO
Explain:____________________________________________________________
Hospitalizations YES /NO Explain:
______________________________________________________
Is there any other medical information you think is important regarding your child?
_____________________________________________________________________________
List any medications your child is currently taking
_____________________________________________________________________________
Early Preschool History
Is your child currently attending a PRESCHOOL program? YES /NO where?_________________
How often does your child attend this program?
____________________________________________
Has your child attended a PRESCHOOL program in the past? YES /NO
Where?__________________________________When?______________________
How often did your child attend this program?_________________________________________
Is your child currently receiving CHILD CARE from someone other than parents? YES /NO
If YES: Is your child attending: HOME DAY CARE / DAY CARE FACILITY
How often does your child receive child care?_________________________________________
Child Care Provider’s
Name:_____________________________________Phone:_________________
Has your child ever received the following:
Speech and Language Evaluation YES /NO Where?_______________ When?___________
Results:
____________________________________________________________________________
Speech and Language Therapy YES /NO Where? __________________ When?__________
Hearing Evaluation YES /NO Where?_________________________ When?_______________
Results:
____________________________________________________________________________
Vision Evaluation YES /NO Where?__________________________ When?______________
Results:_______________________________________________________________________
Developmental Screening/Evaluation YES /NO
Where?_________________When?____________
Results:_______________________________________________________________________
Psychological Evaluation YES /NO Where?____________________ When?______________
Results:_______________________________________________________________________
Occupational Therapy YES /NO Where?_______________________ When?_______________
Physical Therapy YES /NO Where?___________________________ When? _____________
Any other evaluations or services your child has received?_______________________________
_____________________________________________________________________________
_____________________________________________________________________________
Developmental History
Language Development
At what age did your child speak his/her first word?________________What was that word? ___
At what age did your child use: Two words together?______________Speak in sentences? ____
Does your child communicate using gestures? YES /NO Examples: ______________________
Give examples of some things your child might say: ___________________________________
Does anyone have difficulty understanding your child’s speech? YES /NO Explain:___________
Are you concerned about your child’s fluency (stuttering)? YES /NO
Explain:_______________
Did your child ever start talking and then stop? YES /NO
Explain:______________________________
Does your child understand when he is spoken to? YES /NO
Example:_________________________
Is your child able to follow simple directions? YES /NO
Example:______________________________
Social/Emotional Development
Describe how your child plays with other children?_____________________________________
Describe how your child shares toys with other children?________________________________
Does your child engage in an activity for a reasonable length of time? YES /NO
Example:___________
Does your child become easily frustrated? YES /NO
Example:_________________________________
Does your child separate from you easily? YES /NO
Explain:__________________________________
Does your child have extreme fears? YES /NO
Example:_____________________________________
Does your child have frequent tantrums? YES /NO
Example:__________________________________
Do you have concerns regarding your child’s behavior?_________________________________
Other information you would like to share regarding your child’s social and emotional
development?
_____________________________________________________________________________
Physical Development
At what age did your child: Sit up unassisted__________Crawl ___________Walk____________
Does your child prefer one hand over the other? YES /NO
LEFT
RIGHT
Does your child have any weakness in arms or legs? YES /NO Explain: ____________________
Does your child like to run? YES /NO
Does your child pedal a tricycle, big wheel, or bike? YES /NO
Does your child use markers or crayons to make marks on paper? YES /NO
Do you consider your child clumsy or showing poor control of body movements? YES /NO
Explain:
_____________________________________________________________________________
Adaptive Behavior Development (Self Help Skills)
Is your child toilet trained? YES /NO DAYTIME / NIGHTTIME
Explain________________________
Does your child feed her/himself? YES /NO
FINGER FOOD / UTENSILS
Does your child drink from a cup without spilling? YES /NO
SIP CUP / REGULAR CUP
Does your child dress her/himself? YES /NO PARTIALLY / COMPLETELY
Describe the things about your child’s development that please you the most________________
_____________________________________________________________________________
Describe the things about your child’s development that worry you the most _________________
_____________________________________________________________________________
CHILD’S COGNITIVE AND EDUCATIONAL BACKGROUND:
Child comprehends directions and situations as well as other children
yes
no, why not?
Child's level intelligence in comparison to other children:
below average
average
above average
SCHOOL HISTORY Rate child's school experiences:
School level Preschool Kindergarten Grade 1-3
Grade 4-5
Grade 6-8
Grade 9-12
Academic
Good
Average
Poor
Good
Average
Poor
Good
Average
Poor
Good
Average
Poor
Good
Average
Poor
Good
Average
Poor
Socially/
Behaviorally
Good
Average
Poor
Good
Average
Poor
Good
Average
Poor
Good
Average
Poor
Good
Average
Poor
Good
Average
Poor
At what grade level is your child functioning in:
Reading:
Spelling:
Arithmetic:
Has child ever had to repeat a grade?
no
yes, when?
Child is currently placed in a:
regular class
special class (specify):
Child is currently receiving special services and counseling:
no
yes (specify):
Child's teacher reports child's problem in paying attention or concentrating in:
Situations during
No
problem
Minor
problem
Major
problem
Severe
problem
individual work times
small groups
free-play time in class
lectures in class
field trips
special assemblies
movies, videos,
filmstrips
class discussions
Child's teacher describes the following as significant classroom problems:
does not sit still in seat
frequently gets up and walks around classroom
shouts out, does not wait to be called on
won't wait for personal turn
doesn't cooperate well in group activities
typically does better in a one to one relationship
doesn't respect the rights of others
doesn't pay attention during circle time, storytelling or "show and tell"
Describe your concerns about child's school performance:
SIBLING & PEER RELATIONSHIPS
Child gets along with siblings:
doesn't have any
better than average
average
worse than average
Child seeks out friendships with peers:
yes
no
Child is sought out by peers for friendship:
yes
no
How easily does the child make friends:
easier than average
average
worse than average
Child plays primarily with children who are:
same age
older
younger
Describe what problems child has with peers:
INTERESTS AND ACCOMPLISHMENTS
What are child's main hobbies or interests?
What are child's areas of greatest accomplishment?
What does child enjoy doing most?
What does child dislike the most?
HOME BEHAVIORS
Child displays the following behaviors to an excessive or exaggerated degree when
compared to other children the same age:
hyperactivity (high activity level)
poor attention span
impulsivity (poor self control)
temper outbursts
low frustration threshold
sloppy table manners
interrupts frequently
doesn't listen
sudden outbursts of physical abuse of other children
acts like driven by a motor
wears out shoes more frequently than other siblings
heedless to danger
excessive number of accidents
does not learn from experience
poor memory
more active than siblings or children same age
a "different child"
Types of Discipline used in Home:
verbal reprimands
time out
removal of privileges
rewards
physical punishment
acquiescence to child
avoidance of child
redirection
To what extent are the two guardians in the home consistent with disciplinary strategies:
most of the time
some of the time
none of the time
Have any of the following stress events occurred within the past 12 months?
parents divorced or separated
family accident or illness
death in family
parent changed job
changed schools
family moved
family financial problems
other (specify):
Child has problems paying attention or concentrating in any of the following:
Situations when
playing alone
playing with other children
mealtimes
getting dressed
watching TV
visitors are in the home
visiting someone else
at religious services
in supermarkets, stores,
restaurants or public places
asked to do chores at home
during conversations with
others
in the car
asked to do school homework
No
problem
Minor
problem
Major
problem
Severe
problem
Check the box which best describes your child:
Behavior
Not at Just a
all
little
Pretty
much
Very
much
often fidgets or squirms in seat
has difficulty being seated
is easily distracted
has difficulty awaiting turn in groups
often blurts out answers to questions
has difficulty following instructions
has difficulty sustaining attention to tasks
often shifts from one uncompleted activity to
another
has difficulty playing quietly
often talks excessively
often interrupts or intrudes on others
often does not seem to listen
often loses things necessary for tasks
often engages in physically dangerous
activities without considering consequences
Check the box which best describes your child's current behaviors:
Behavior
fails to finish things which were started
can't concentrate, can't pay attention for long
can't sit still, restless, or hyperactive
fidgets
daydreams or gets lost in thoughts
impulsive or acts without thinking
difficulty following directions
talks out of turn
messy work
inattentive, easily distracted
talks too much
fails to carry out assigned tasks
Not true Somewhat true Very true
Has child displayed any of the following:
stereotyped mannerisms
odd postures
excessive reaction to noise or fails to react to loud noises
overreacts to touch
compulsive rituals
perseveration
self-stimulation
motor tics
vocal tics
ADDITIONAL REMARKS which will help in assessing your child's needs: