Home Our Team Service Partners Our Place Resources Pay Your Bill Contact Us Developmental History Form Step 1 of 7 14% Form Completed By First Last Email PhoneChild's Name First Last BirthdateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age Grade School Medical DiagnosisIs your child receiving any other therapy services?Is your child participating in any social/community activities?What are your child's favorite play interests?What are your primary concerns for your child? ( Academic, behavioral, communication, social, sensory, gross/fine motor) Family MembersFather's Name First Last Father's Occupation Mother's Name First Last Mother's Occupation Marital Status Married Separated Divorced SiblingsNameAgeSex PregnancyAny complications/health problems? Yes No Was bed rest recommended? Yes No Any exposure to smoke, alcohol or environmental toxins? Yes No Was mother physically active? Yes No Any emotional trauma or stress? Yes No If you answered yes to any of the questions above, please elaborate below.Labor and DeliveryWas delivery at full term? Yes No If not, gestational age If vaginal delivery, was there: Induced labor Forcep or vacuum assist If caesarean birth, was it Planned Emergency What was the reason for the caesarean birth?What was the delivery position? For example, breechWas an oxygen assist necessary? Yes No Structural abnormalities noted at birth (cleft lip, torticollis, etc.)?Birth weight? APGAR Scores? If you answered yes to any of the questions above, please elaborate below. Also note any additional complications (i.e jaundice, difficulty feeding, weight loss, delayed discharge from the hospital):Is the child adopted? Yes No AdoptionAge when adopted? Country adopted from? Any known pregnancy and delivery informationAny known family health historyIs your child aware of adoption? InfancyPlease check all that apply Breast-fed Bottle-fed Difficulty feeding Easy-going Fussy, irritable Colicky Floppy Tense muscles Poor sleep patterns Hard to console Difficulty riding in a car seat Pacifier/Thumb What comforted your infant? Swaddling Rocking/Motion Sucking/mouthing Vibration Did anything else comfort your infant? And do you have any additional comments? Childhood HealthPlease mark all that apply Ear infections Respiratory problems/asthma Frequent colds Strep throat High fever Seizures Chronic stomachaches Constipation Limited food intake Bedwetting Difficulty falling asleep Fitful sleep Skin problems Nail biting Extended thumb sucking Antibiotic use Significant falls or injuries Hospitalization Allergies Other Please list the age and how often the incidents occurred. Also describe any significant falls/injuries, reasons for hospitalization, allergies, and any other childhood health issues.Is your child in good general health at the present time? How many hours of sleep does your child average at night? What types of foods does your child like to eat at this time?If your child is a picky eater or resistant to new textured foods, please describe.Have you established a tooth brushing routine? Yes No How does your child respond?Does your child drink from a cup? Yes No If yes, what type: sippy, straw, regular? Does your child cough when eating or drinking? If yes, please describe.Please list current medicationsPlease list current dietary supplementsAre immunizations up-to-date? Yes No Developmental TeamWhich of the following specialists has your child seen, or is currently seeing for an evaluation or treatment? Please bring any current reports you may have. Neurologist Psychologist Psychiatrist Speech Pathologist Audiologist Physical Therapist Occupational Therapist Developmental Optometrist Ophthalmologist Nutritionist/Dietitian Allergist Gastroenterologist For any of the specialists seen, please list their name, date seen, and any findings.EmailThis field is for validation purposes and should be left unchanged. Δ
