Child History Form
Cheryl C. Holland, Ph.D.
Licensed Psychologist
10605 Concord Street, Ste. 100
Kensington, Maryland 20895
(301) 962-0800, ext. 3
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Child History Form
CHILD BACKGROUND HISTORY FORM
Child’s Name: ______Date of Birth ____
Gender: __ M___F
Mother’s Name: ______
Father’s Name: ______
Please List all People Living in Child’s Home:
NameRelationshipAge
Reason for Referral/Concerns:
Any Precipitating Factors or Stressors:
Strengths/Interests/Hobbies:
Previous Evaluations:
EvaluationsYes/NoDateAgency/Person
Educational/Psychological Testing
Occupational Therapy Evaluation
Physical Therapy Evaluation
Speech/Language Evaluation
Previous/Current Therapy & Intervention:
ServiceDate(s)Agency/Person
Counseling/Therapy
Occupational Therapy
Physical Therapy
Speech/Language Therapy
Tutoring
Vision Therapy
Other:
Birth and Developmental History:
Was mother’s health during pregnancy good to excellent?
Was baby born at term (due date) or within two weeks before/after due date?
What was child’s birth weight?
Any concerns with labor/delivery?
Were there any feeding problems?
Were there any sleeping problems?
During the first several months of life, was baby’s health good?
Describe baby’s general temperament in the first 18 to 24 months:
Developmental Milesones:
AgeAdditional Information
When did crawling emerge?
When did walking emerge?
When did child begin to babble?
When did child produce first words?
When did child begin combining
words?
Communication:
Is your child able to communicate in words?
Does your child seem to understand what is said?
Does your child follow spoken directions?
Is your child understood by others?
Does your child often hesitate when speaking and/or repeat sounds/words/phrases?
Other Comments:
Gross Motor:
Is there a history of problems with gross motor skills (walking, running, climbing?)
Are there currently any problems with gross motor skills?
Is there a history of problems with fine motor skills (e.g. picking up objects, dressing?)
Are there currently any problems with fine motor skills?
Which hand does child use most often?
Other Comments:
Medical History:
Has child ever had a fever of 104 degrees or more?
Is child currently under treatment for any medical condition?
Are there any problems with vision?
Has child had vision screened or tested?
Does child wear corrective lenses for vision?
Does child sleep well? Sleep Issues?
Does child have a good appetite? Eating Issues?
Is child on a special diet?
Other Comments:
Does your child take prescription or over-the-counter medication regularly?
MedicationDosePrescribing Physician (if applicable)
History of Medical Problems(Please circle if applicable)Age
Allergies (i.e. food, insect bites, latex, pollen,
medication, etc.)
Chronic Colds
Ear Infections
Measles
Mumps
Spasms, convulsions, or seizures
Tonsillitis
Other
Please provide information regarding any injury, surgeryAge
Or hospitalization:
Behavioral Concerns: (Please circle if applicable)
ConcernAgeAttempts to Modify Behavior/Treatment
Bedwetting
Depression
Nervousness/Anxiety
Difficult separating from
parents
Difficulty sitting still
Frequent headaches/
stomachaches
History of trauma
Inability to stay with one
activity until completion
Behavioral Concerns Continued: (Please circle if applicable)
ConcernAgeAttempts to Modify Behavior/Treatment
Negative self-esteem
Noncompliance/Defiance
Aggression
Social Skills Problems
Excessive Shyness
Sensory Sensitivities
Sleeplessness
Nightmares
Strong fears
Temper Tantrums
Isolated Play
Other:
Educational History:
Name of School: ______Current Grade: ___
Previous School(s):
Has child ever repeated a grade? Please describe including grade(s) repeated.
Are there any current concerns regarding school performance? Please describe.
Does child receive any special services at school? Please describe.
Day Care History:
Please provide early child care history prior to attending elementary school (if applicable).
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2.
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Friendships/Social Skills:
Please provide description of strengths/concerns in the following areas:
Initiating social interactions:
Maintaining social interactions:
Developing age appropriate friendships:
Exhibiting age appropriate friendship skills:
How many close friendships does your child have currently?:
Name of Person Completing this Form:
Relationship to Child:
______
SignatureDate
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