Developmental History Sample Clauses

Developmental History. Age began sitting: crawling: walking: talking: *Does your child pull up? *Crawl? *Walk with support? Any speech difficulties? Special words to describe needs Language spoken at home *Any history of colic? *Does your child use pacifier or suck thumb? *When? *Does your child have a fussy time? *When? *How do you handle this time? Any known complications at birth? Serious illnesses and/or hospitalizations: Special physical conditions, disabilities: Allergies i.e. asthma, hay fever, insect bites, medicine, food reactions: Regular medications: Special characteristics or difficulties: *If infant is on a special formula, describe its preparation in detail: Favorite foods: Foods refused: * Is your child fed held in lap? High chair? * Does your child eat with spoon? Fork? Hands? *Are disposable or cloth diapers used? *Is there a frequent occurrence of diaper rash? *Do you use: oil: powder: lotion: other: *Are bowel movements regular? How many per day? *Is there a problem with diarrhea? Constipation? *Has toilet training been attempted? *Please describe any particular procedure to be used for your child at the center: *What is used at home? Pottychair? Special child seat? Regular seat? *How does your child indicate bathroom needs (include special words): _ Is your child ever reluctant to use the bathroom? _ Does your child have accidents? *Does your child sleep in a crib? Bed? Does your child become tired or nap during the day (include when and how long)?

Developmental History. Pregnancy Delivery Infancy (developmental milestones) Middle childhood (developmental milestones) Young adulthood (developmental milestones)

Developmental History. DID YOUR BIRTH MOTHER EXPERIENCE ANY TRAUMATIC EVENTS, DEATHS OF SIGNIFICANT OTHERS OR HIGH STRESS SITUATIONS DURING HER PREGNANCY WITH YOU? IF YES DURING WHAT TRIMESTER WHAT WAS THE EVENT? _ WERE YOU A FULL TERM BABY? _ IF NO, HOW PREMATURE WERE YOU? _ WEEKS. PREGNANCY COMPLICATIONS WITH YOU (CHECK ALL THAT APPLY): ☐NONE ☐DRUG USE ☐ALCOHOL USE ☐ MENTAL ILLNESS ☐ DOMESTIC VIOLENCE/SEXUAL ASSUALT/EMOTIONAL ABUSE. HOW DO YOU DESCRIBE YOUR CHILDHOOD HEALTH? ☐NORMAL ☐FREQUENT EAR INFECTIONS/TUBES IN EARS ☐ DEVELOPMENTAL DELAY ☐HEAD INJURY(S) ☐ SCHOOL IEP ☐ ADHD/ADD ☐ SELF INJURING BEHAVIOR/SUICIDAL THOUGHTS ☐ SEIZURES ☐SIGNIFICANT INJURIES ☐HOSPITALIZATIONS ☐FREQUENT ER VISITS ☐CHRONIC/SERIOUS HEALTH PROBLEMS ☐SIGNIFICANT/UNUSUAL ILLNESSES ☐OTHER INFANCY: ☐NONE ☐ SLEEPING PROBLEMS ☐ DIFFICULT TO SOOTHE ☐ FEEDING PROBLEMS ☐ TOILET-TRAINING PROBLEMS ☐CHOLIC ☐OTHER: DELAYED MILESTONES: ☐NONE ☐SPEECH ☐ TOLERATING SEPARATION ☐ BODY CONTROL ☐ PLAYING COOPERATIVELY ☐ ROLLING OVER ☐ BLADDER CONTROL ☐ BOWEL CONTROL ☐ RIDING TRICYCLE/BICYCLE ☐SITTING ☐ STANDING ☐ WALKING ☐ DRESSING SELF ☐ PERSONAL HYGIENE ☐ FEEDING SELF ☐ ENGAGING PEERS/MAKING FRIENDS ☐ READING ☐OTHER: _

Developmental History. Have there been any developmental delays? Have there been any periods of rapid weight gain or weight loss? Supports self in standing position Xxxxxx trained Weaned off breast milk Ties shoes First Tooth Dresses without help Crawls Hits Puberty First word (besides mama, dada) First menstruation Walks Was/is the child breastfed? Y/N For how long? Was the child fed formula? Y/N Type (milk, soy, other): At what age was the formula was introduced?: Were/is there any feeding difficulties? Did the child ever have any difficulty gaining weight? Y/N What foods were introduced before 6 months? What foods were introduced between 6-12 months? Did the child react to any of the new foods introduced? Are there any nutritional restrictions (due to ethnicity, ethics, religion, etc.)? If applicable, please indicate the child’s frequency and intake of the following substances: Pop: Water: Caffeine (incl. Chocolate) Breakfast: Lunch: Dinner: Snacks: Beverages: What is the sleeping pattern of the child? Are there any difficulties sleeping? How regularly does the child get exercise? Are there any toxins or other hazards to which the child is regularly exposed?

Developmental History. Did you have problems in health or development during birth, infancy, childhood? ❒ Normal, Unremarkable ❒ Not Relevant ❒ Relevant ❒ Note:

Developmental History. Where there any complications with your mother’s pregnancy or with your birth, or were you born prematurely? ( ) Yes ( ) No ( ) Unsure Did you experience any difficulty learning to walk, talk, read, write or reach any other developmental milestone(s)? ( ) Yes ( ) No ( ) Unsure Was there any type of child abuse in your family? ( ) Yes ( ) No ( ) Unsure How many siblings do you have? How would you describe your childhood? Were you ever formally tested for and/or diagnosed with a learning disability? ( ) Yes ( ) No ( ) Unsure How many years of education have you completed? Have you ever experienced a traumatic event like being robbed, assaulted, raped or having been in combat? ( ) Yes ( ) No ( ) Unsure If “yes”, please explain: Are you involved in any lawsuit or legal matter with whom you want the doctor’s help by sending reports, evaluations, etc. to an attorney or to the court? ( ) Yes ( ) No If “yes”, please explain: Have you ever had legal problems, arrests, been in jail or prison? ( ) Yes ( ) No If “yes”, please explain: Please list anything else you think is important for your provider to know about your psychological or social history: Which of the following conditions are you currently being treated or have been treated for in the past? (Please Check)

Developmental History. Age at which child crawled? Sat? Walked? Began toilet training: Completed? Can child dress unassisted? Undress? Right or Left handed? Additional Information: Does child follow daily routine? How does child react to change in routine? What time does child eat breakfast? Lunch? Dinner? Naptime? How Long? Bedtime: Awakes at what time? Does child sleep well? Any special fears? What causes child to show temper? What methods of behavior control are used in your home? Frequent colds? Runs high fever easily? History of ear problems (infections, tubes, etc.) Ever had a seizure? If so, explain: Have you suspected or detected any speech problems? Please check any and all that apply: ❏ ❏ ❏ Hearing Problems Wears hearing aids? Vision Problems Wears corrective lenses? Food Allergies ❏ Downs Syndrome ❏ Speech/Language Delay ❏ Motor Development Delay ❏ Sensory Processing Challenges ❏ Autism Spectrum Disorder ❏ Asthma (Asthma Action Plan from doctor is REQUIRED if any medication is used to manage asthma.) ❏ Any other disease, illness, or diagnosis that would affect his/her Sonshine School day ❏ None of the Above Any hospitalizations or injuries in the past year? If so, what? Any medications prescribed for long-term or continuous use? If so, what?

Developmental History