SUTCLIFFE DEVELOPMENTAL & BEHAVIORAL PEDIATRICS
851 Fremont Avenue, Suite 110, Los Altos, CA 94024
p. 650-941-1698 | f. 650-434-3953
www.sutcliffedbp.com
Patient Name:
Date of Birth:
Gender preference:
Caregiver Name(s):
Address:
Phone
Email:
Reason for referral:
Referring party:
Are there any special considerations you would like us to know about your family and/or accommodate?
(i.e. cultural, linguistic, communication-related, physical, spiritual, gender, or sexual orientation consideration):
How did you hear about this clinic?
Your Child’s Medical Home
Primary care provider (PCP) name:
PCP address:
PCP office phone:
PCP e-mail (if available):
What individuals or services do you consider to be on your child’s medical “team” and would like us to keep
updated with information pertinent to your child’s developmental and behavioral plan? Please include their
medical specialty and their contact information
HISTORY OF CURRENT CONCERNS
What are your chief concerns and/or goals for this appointment?
Do your have any concerns regarding your child’s… If yes, please explain.
NO / YES
☐ / ☐ Behavior:
☐ / ☐ Current or recent pain:
☐ / ☐ Nutrition:
☐ / ☐ Significant weight gain/loss recently:
☐ / ☐ Movement or ability to walk:
☐ / ☐ Seeing, hearing, or speech:
☐ / ☐ Ability to execute activities of daily living:
☐ / ☐ Sleep:
☐ / ☐ Stooling patterns:
What do you believe is the root or reason(s) for these behaviors and/or development issues?
Child’s greatest strengths:
Child’s areas of desired improvement:
His/her “likes”:
His/her “dislikes”:
SUTCLIFFE DEVELOPMENTAL & BEHAVIORAL PEDIATRICS
851 Fremont Avenue, Suite 110, Los Altos, CA 94024
p. 650-941-1698 | f. 650-434-3953
www.sutcliffedbp.com
PAST MEDICAL HISTORY
Outside of the primary care provider, what medical providers have helped your child in the past? Please
include their medical specialty and their contact information:
Does you child have…
NO / YES
☐ / ☐ any current or previous illnesses?
☐ / ☐ any issues with hearing or vision?
☐ / ☐ any injuries to the body or the head from a past even?
☐ / ☐ any history of hospitalizations?
☐ / ☐ any surgical history of note?
☐ / ☐ any history of trauma?
Are your child’s immunizations up to date?
☐ YES / ☐ NO
Medication History
Is you child currently taking any medications? ☐ YES / ☐ NO
If yes, please list the medication and dose:
Has your child used any psychopharmacologic treatment in the past?
If yes, what was the drug(s), dose details, and response
☐ YES / ☐ NO
Do you use any over-the-counter, alternative therapies, or herbal remedies?
If yes, what do you use and for what purpose?
☐ YES / ☐ NO
Does your child have any allergies or sensitivities that you have documented or noticed?
If yes, please tell us more about the triggers and your child’s response.
☐ YES / ☐ NO
Birth & Neonatal History
Including this birth, there are… ______ pregnancies, ______ miscarriages, ______ children in the family
Maternal age at time of birth? _______
Prenatal care during pregnancy: ☐ YES / ☐ NO
During the pregnancy, was the mother healthy? ☐ YES / ☐ NO
If no, please check any that apply: none / excessive vomiting / hypertension / gestational diabetes /
hyperemesis / unexplained fevers /
Did your child have any in-utero exposure to substances\medications?
Did your child have any in-utero exposure to trauma? ☐ YES / ☐ NO
☐ YES / ☐ NO
Was your child considered a premature, near-term, term, or post-term infant?
premature / near-term /
term / post-term
What type of delivery was the birth: cesarean / vaginal
Was there any augmentation used?
none / pitocin / epidural
Was there any instrumentation used during the birth?
none / vacuum-assist / forceps / electrodes
/ other
Were there any complications during the delivery? ☐ YES / ☐ NO
If so, please explain:
SUTCLIFFE DEVELOPMENTAL & BEHAVIORAL PEDIATRICS
851 Fremont Avenue, Suite 110, Los Altos, CA 94024
p. 650-941-1698 | f. 650-434-3953
www.sutcliffedbp.com
Birth weight:
Birth length:
Head circumference:
Apgar scores, if available:
How many days did your child spend in the hospital total? Small number field
Did your child spend any time in the neonatal intensive care unit (NICU)? ☐ YES / ☐ NO
If so, please explain:
Did your child experience any difficulties in the first 6 months of life? ☐ YES / ☐ NO
If so, please explain: text box
Early feeding for the child? breastfeeding only / breast and formula / formula / other
Were there are therapies used early on to help your child thrive? ☐ YES / ☐ NO
If so, please explain: text box
Developmental History
Did your child reach all of his/her developmental milestones on time? ☐ YES / ☐ NO
If not, please describe:
If so, at what age did you begin to notice any developmental or behavior difficulties in your child?
Was there any regression in your child’s skills or ability? ☐ YES / ☐ NO
If yes, please explain:
Did your child’s head circumference ever decrease or fall off its growth curve? ☐ YES / ☐ NO
Whom are your child’s service providers? Please include a contact name and their contact information.
☐ Regional Center:
☐ CCS:
☐ ABA therapy:
☐ Occupational therapy
☐ Physical therapy
☐ Speech/Language:
☐ Other:
Education History
School Name:
Grade:
District:
Type of class:
Teacher:
Do you child have an IEP or 504 in place with the school? ☐ YES / ☐ NO
If yes, when was the last review meeting?
Are you happy with your current school services and plan? ☐ YES / ☐ NO
If no, please explain.
Family History
The following people live with the child:
Relationship
Name
Age
Was patient adopted? ☐ YES / ☐ NO
Highest level of
education
Occupation
SUTCLIFFE DEVELOPMENTAL & BEHAVIORAL PEDIATRICS
851 Fremont Avenue, Suite 110, Los Altos, CA 94024
p. 650-941-1698 | f. 650-434-3953
www.sutcliffedbp.com
Are there any current family stressors? ☐ YES / ☐ NO
Has your child been exposed to second-hand smoke or other known toxins?
If yes, please explain:
Does your child see a dentist regularly?
Family medical history
Name, relation
Medical issue
☐ YES / ☐ NO
☐ YES / ☐ NO
Details and onset
Does anyone in the extended family suffer from… Please circle
developmental delays / learning differences / intellectual disabilities / autism or autistic-like behaviors /
attention deficit disorder / depression / anxiety / mental health disorders / problems with weakness or muscular
concerns / language
difficulties / movements disorders / motor or verbal tics / other
Circle all the documents that you already have and could following documents
☐ Section 504 Accommodation Plan
☐ Progress Reports, Student Success Team
☐ IEP Evaluation
notes
☐ Academic Assessment Report
☐ Regional Center Evaluation
☐ Psychoeducational Evaluation
☐ STAR Student Reports
☐ Speech and Language Initial Evaluation
☐ Teacher letters
☐ Other: