Childhood History Form

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Myles L. Cooley, Ph.D., ABPP

CHILDHOOD HISTORY FORM

Person completing this form (Circle all)Mother Father Step-mother Step-father Other

Child’s Name ______Age______

Grade ______Birthdate ______Sex M F

Was the child adopted? Yes No If yes, at what age?______

Has the child repeated a grade? Yes No If yes, what grade ______

and why? ______

Has the child been tutored? Yes No If yes, by whom, ______

for how long, and in what subjects?______

Has the child been diagnosed with a learning, attention or emotional problem?YesNo

If yes, what problem ______

Diagnosed by whom ______when ______

Does the child receive accommodations in school? Yes No What are they?______

______

Medications child currently takes (Names and dosages)______

______

Briefly describe the child’s teacher’s concerns. ______

______

Which subjects are difficult? _____Reading _____Math _____Written Work

Briefly describe concerns you have with behavior at home.______

______

PARENT HISTORY

Mother:Occupation ______

Education (Highest grade completed) ______

Have you or any of your blood relatives (e.g. parents, siblings, nieces, nephews) had similar problems to those of your child? Yes No

If yes, describe ______

______

Psychological or substance abuse problems in you or relatives? Yes No

If yes, describe______

Father:Occupation ______

Education (Highest grade completed) ______

Have you or any of your blood relatives (e.g. parents, siblings, nieces, nephews) had similar problems to those of your child? Yes No

If yes, describe______

______

Psychological or substance abuse problems in you or relatives? Yes No

If yes, describe______

Have any of your child’s siblings had similar problems? Yes No

If yes, describe______

PREGNANCY AND DELIVERY

Length of pregnancy (weeks) ______

Pregnancy complication? Yes No If yes, describe______

______

Child’s birth weight ______

Type of delivery ______Normal ______Breech ______C-Section

Delivery complication(s): ______Cord around neck ______Born blue ______Turned yellow

______Trouble breathing ______Infection ______Injury - describe ______

TEMPERAMENT

Birth to 2 years3 - 4 years

Was your child: (Circle)

Difficult to feed Y N Y N

Difficult to get to sleep or napY N Y N

Difficult to comfort Y N Y N

Colicky Y N Y N

Irritable Y N Y N

Stubborn, demanding Y N Y N

Overly active, into everythingY N Y N

MEDICAL HISTORY

Has your child had: (Circle)

Allergies/AsthmaSeizuresHead Injury Speech & language problems

Chronic ear InfectionsEye problems/glassesBedwetting

Tics (e.g. eye blinking, sniffing, throat clearing, any repetitive movements) Describe______

______

Fine motor/handwriting problems Gross motor problems, clumsiness

Other ______

DEVELOPMENTAL MILESTONES

Early On Time Late

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Walked without assistance ______

Spoke single words ______

Spoke two or more words together ______

Bladder trained ( night) ______

Bowel trained (day) ______

Rode bicycle (without training wheels)______

Buttoned clothes ______

Tied shoelaces ______

Names colors ______

Said alphabet in order ______

HOME & SCHOOL BEHAVIORS

All children sometimes exhibit the behaviors listed below. Write a P (Parent), T (Teacher) or B (Both) next to the behavior if the parent and/or teacher observes it much more frequently compared to other children his or her own age:

P, T, or B

______Often does not follow through on instructions and fails to finish schoolwork, chores.

______Is often easily distracted by extraneous stimuli.

______Often has difficulty sustaining attention to tasks or play activities.

______Often doesn’t seem to listen when spoken to directly.

______Often loses things necessary for tasks or activities (e.g., pencils, toys, books).

______Often fails to give close attention to details or makes careless mistakes in schoolwork or other activities.

______Often forgetful in daily activities.

______Often avoids or strongly dislikes tasks (e.g., schoolwork, homework) that require sustained mental effort.

______Often has difficulty organizing tasks and activities.

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P, T, or B

______Often has difficulty awaiting turn in groups, games or waiting in lines.

______Often blurts out answers to questions before questions are completed.

______Often interrupts or intrudes on others.

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______Often fidgets with hands or feet or squirms in seat.

______Often leaves seat in classroom or in other situations in which remaining seated is expected.

______Often runs about or climbs excessively in situations where it is inappropriate. ( In adolescents, restlessness.)

______Often has difficulty playing or engaging in leisure activities quietly.

______Often talks excessively.

______Is often “on the go” or often acts as if “driven by a motor.”

______Often loses temper

______Often argues with adults

______Often actively defies or refuses to comply with adults’ requests or rules

______Often deliberately annoys people

______Often blames others for his or her mistakes or misbehavior

______Is often touchy or easily annoyed by others

______Is often angry and resentful

______Is often spiteful or vindictive

______

______Worries

______Fearful of separation

______Shy

______Cries easily

______Has to have or do things a specific way

______Complains of headaches, stomachaches

______Poor self-esteem

______Withdrawn, few friends

______Has repetitive behaviors or habits

______Excessive fears

______Difficulty falling asleep