Section 6: Developmental History

* Indicates required field

Child's name *

First

Last

Today's Date *

Form completed by (include relationship to child) *

If the child was adopted, please indicate at what age. *

During pregnancy, did the mother... *

Take any prescription medication (please indicate what kind, for what problem, during what month, and for how long) Smoke (please indicate how many cigarettes each day) Drink alcoholic beverages (please indicate what kind and approximately how much alcohol was consumed each day/week) Use drugs (please indicate what kind) Experience any complications (excessive vomiting, excessive staining/blood loss, threatened miscarriage, infections(s), toxemia, etc) (please describe) None of these

For each option checked, please indicate the requested details. *

Duration of pregnancy (weeks) *

Duration of labor (hours) *

During labor or delivery... *

There were indications of fetal distress (please describe) Forceps were used (please indicate the reason) A Cesarean section was performed (please indicate the reason) Delivery was induced (please indicate the reason) Delivery was breach Delivery was spontaneous normal vaginal delivery (SNVD) Child was premature (please indicate by how many weeks) There were birth defects or complications (please describe)

APGARS *

Additional APGARS *

Describe any depression during the immediate post-natal period. *

What was your first impression of your baby? *

For each option checked, please indicate the requested details. *

Showed response to mother at age... *

Smiled *

Rolled over *

Sat alone *

Crawled *

Walked without assistance *

Babbled *

Spoke first word *

Spoke single words (other than "mama" or "dada") *

Vocabulary burst *

Said phrases *

Said sentences *

Dressed self (donning shirts/pants) *

Buttoned clothing *

Managed all fasteners *

Donned socks and shoes *

Tied shoelaces *

Began to use utensils *

Mastered utensils *

Bladder trained, day *

Bladder trained, night *

Stayed dry at night *

Bowel trained *

Rode tricycle *

Rode bicycle (without training wheels) *

Named colors *

Named shapes *

Named coins *

Said alphabet in order *

Identified all letters accurately *

Began to read *

My child's walking ability is *

My child's running ability is *

My child's throwing ability is *

My child's catching ability is *

My child's overall athletic ability is *

My child's shoelace tying is *

My child's cutting ability is *

My child's ability to manipulate small objects is *

My child's writing (graphomotor) ability is *

If you would like to qualify any responses or add additional notes, please do so here. After you click "submit," you will be redirected to the For Clients page. *

Background Questionnaire

Section 6: Developmental History