Child Developmental History Record

Adult History Form

Today’s date

IDENTIFYING INFORMATION

Name Birthdate Age

Sex ❑ Female ❑ Male

Address

Home phone Work phone Cell phone

Email address

Primary Language Secondary Language

Ethnicity Religious/Spiritual Beliefs

REASON FOR REFERRAL

Why are you seeking help?

Who referred you to my service?

FAMILY HISTORY

Where were you born?

Please identify all locations of residency

Location / Dates of residency / Reason for moving

Please list members of your family of origin:

Relative: / Name: / Current Age (or age of death) / Education/Occupation
Mother
Father
Stepparents
Grandparents
Aunts/Uncles
Brothers
Sisters

With whom do you live?

Current marital status: ❑ Married ❑ Single ❑ Divorced ❑ Widowed ❑ Separated

Please list all of your children:

Name / Age / Sex / From current relationship or previous relationship?

EARLY HISTORY

Complications during your mother’s pregnancy with you? ❑ No ❑ Yes (if yes, describe)

Were you born: ❑ On time ❑ Prematurely ❑ Late

Birth Weight lbs oz

Check any of the following complications that occurred during birth:

❑ Forceps Used ❑ Vacuum Extraction ❑ Breech Birth ❑ Labor Induced

❑ Caesarean Delivery (if yes, describe reason)

❑ Other Delivery Complications (if yes, describe)

Rate your developmental progress to the best of your knowledge:

Walking: ❑ Early ❑ Average ❑ Late

Talking: ❑ Early ❑ Average ❑ Late

Toilet Training: ❑ Early ❑ Average ❑ Late

As a child, did you have any of these conditions? (Check all that apply)

Frequent ear infections ❑ No ❑ Yes / Behavioral problems ❑ No ❑ Yes
Clumsiness ❑ No ❑ Yes / Speech problems ❑ No ❑ Yes
Developmental delay ❑ No ❑ Yes / Vision problems ❑ No ❑ Yes
Attention problems ❑ No ❑ Yes / Social problems ❑ No ❑ Yes
Head injury ❑ No ❑ Yes / Anxiety ❑ No ❑ Yes
Hearing Problems ❑ No ❑ Yes / Depression ❑ No ❑ Yes
Hyperactivity ❑ No ❑ Yes / Autistic Spectrum Disorder ❑ No ❑ Yes
Learning Disability (specify type) ❑ No ❑ Yes / Other (Specify) ❑ No ❑ Yes

HEALTH

Please list all illnesses, hospitalizations, head injuries, important accidents and injuries,

surgeries, periods of loss of consciousness, convulsions/seizures, and other medical conditions.

Condition / Age / Treatment/consequence? / Required hospitalization? (if yes, how long)

Are you currently taking any medications? ❑ No ❑ Yes

If yes, please indicate type and reason?

Do you have any allergies? ❑ No ❑ Yes If yes, please describe

Have you ever received psychological counseling or therapy? ❑ No ❑ Yes

If yes, please indicate counselor’s name and duration of treatment?

Brief description of reason for treatment

Have you ever received psychiatric care? ❑ No ❑ Yes

If yes, please indicate doctor’s name and duration of treatment?

Brief description of reason for treatment

FAMILY HEALTH

Please provide health information for your family members.

Condition / Family Member (M=mother, F=father, S=sibling,
C=child, MGP= maternal grandparent; PGP=paternal grandparent, etc)
Attention Deficit Disorder ❑ No ❑ Yes
Anxiety ❑ No ❑ Yes
Depression ❑ No ❑ Yes
Bipolar Disorder ❑ No ❑ Yes
Learning Disability (specify type) ❑ No ❑ Yes
Alcohol/Drug Abuse ❑ No ❑ Yes
Speech/Language Problems ❑ No ❑ Yes
Autistic Spectrum Disorder ❑ No ❑ Yes
Medical Illness (specify)
Other Medical Illness (specify)
Other (specify)

EDUCATION

Highest grade completed

High School: Yr. Graduated Location:

College: Yr. Graduated Location: Major:

Grad. School: Yr. Graduated Location: Area of Study:

Were you ever retained a grade in school? ❑ No ❑ Yes

If yes, when and why?

Have you ever been tested for special education? ❑ No ❑ Yes

If yes, when and why?

Describe your typical performance as a student (grades)

What was your strongest subject (s)?

What was your weakest subject (s)?

OCCUPATIONAL HISTORY:

Occupation Employer

How long with present employer Job title:

Past Jobs:

Position: Years:

ALCOHOL INTAKE

Beverages per week

TOBACCO/DRUG INTAKE

Do you smoke cigarettes? ❑ No ❑ Yes If yes, how much per week?

Do you have a history of illicit substance use? ❑ No ❑ Yes

Type of drug(s) used:

Frequency of use: