Developmental and Medical History

Developmental and Medical History

DEVELOPMENTAL AND MEDICAL HISTORY

PREGNANCY AND DELIVERY

LENGTH OF PREGNANCY
LENGTH OF DELIVERY
MOTHER’S AGE WHEN CHILD WAS BORN
CHILD’S BIRTH WEIGHT
DID ANY OF THE FOLLOWING CONDITIONS OCCUR DURING PREGNANCY?
YES / NO
  1. BLEEDING

  1. EXCESSIVE WEIGHT GAIN {MORE THAN 30 LB.}

  1. TOXEMIA

  1. RH FACTOR INCOMPATIBILITY

  1. SERIOUS ILLNESS OR INJURY

  1. TOOK PRESCRIPTION MEDICATIONS
    IF YES, NAME OF MEDICATION:

  1. FREQUENT NAUSEA OR VOMITING

  1. TOOK ILLEGAL DRUGS

  1. USED ALCOHOLIC BEVERAGES IF YES, APPROXIMATE NUMBER OF DRINKS PER WEEK:

  1. SMOKED CIGARETTES IF YES, NUMBER PER DAY:

  1. WAS GIVEN MEDICATION TO EASE LABOR PAINS
    IF YES, NAME OF MEDICATION:

  1. DELIVERY WAS INDUCED

  1. FORCEPS USED DURING DELIVERY

  1. HAD A BREECH DELIVERY

  1. HAD A CESAREAN SECTION DELIVERY

  1. OTHER PROBLEMS: PLEASE DESCRIBE

DID ANY OF THE FOLLOWING CONDITIONS AFFECT YOUR CHILD DURING
DELIVERY OR WITHIN A FEW DAYS AFTER BIRTH?
YES / NO
  1. INJURED DURING DELIVERY

  1. CARDIOPULMONARY DISTRESS DURING DELIVERY

  1. DELIVERED WITH CORD AROUND NECK

  1. HAD TROUBLE BREATHING FOLLOWING DELIVERY

  1. NEEDED OXYGEN

  1. TURNED BLUE

  1. WAS JAUNDICED, TURNED YELLOW

  1. HAD AN INFECTION

  1. HAD SEIZURES

  1. WAS GIVEN MEDICATIONS

  1. BORN WITH A CONGENITAL DEFECT

  1. WAS IN HOSPITAL MORE THAN 7 DAYS

INFANT HEALTH AND TEMPERAMENT

DURING THE FIRST 12 MONTHS, WAS YOUR CHILD:
YES / NO
  1. DIFFICULT TO FEED

  1. DIFFICULT TO GET TO SLEEP

  1. COLICKY

  1. DIFFICULT TO PUT ON A SCHEDULE

  1. ALERT

  1. CHEERFUL

  1. AFFECTIONATE

  1. SOCIABLE

YES / NO
  1. EASY TO COMFORT

  1. DIFFICULT TO KEEP BUSY

  1. OVERACTIVE, IN CONSTANT MOTION

  1. VERY STUBBORN, CHALLENGING

EARLY DEVELOPMENTAL MILESTONES

AT WHAT AGE DID YOUR CHILD FIRST ACCOMPLISH THE FOLLOWING:
  1. SITTING WITHOUT HELP

  1. CRAWLING

  1. WALKING ALONE, WITHOUT ASSISTANCE

  1. USING SINGLE WORDS (MAMA, DADA, BALL)

  1. PUTTING TWO OR MORE WORDS TOGETHER

  1. BOWEL TRAINING, DAY AND NIGHT

  1. BLADDER TRAINING, DAY AND NIGHT

HEALTH HISTORY

DATE OF CHILD’S LAST PHYSICAL EXAM:

PLEASE LIST THE SCHOOLS YOUR CHILD HAS ATTENDED AND ANY IMPORTANT INFORMATION ABOUT SCHOOL:______

AT ANY TIME HAS YOUR CHILD HAD THE FOLLOWING:
NEVER / PAST / PRESENT
  1. ASTHMA

NEVER / PAST / PRESENT
  1. ALLERGIES

  1. DIABETES, ARTHRITIS, CHRONIC ILLNESS

  1. EPILEPSY OR SEIZURES

  1. CHICKEN POX OR COMMON CHILDHOOD ILLNESS

  1. HEART OR BLOOD PRESSURE PROBLEMS

  1. HIGH FEVERS (OVER 103)

  1. BROKEN BONES

  1. SEVERE CUTS NEEDING STITCHES

  1. HEAD INJURY WITH LOSS OF CONSCIOUSNESS

  1. LEAD POISONING

  1. SURGERY

  1. LENGTHY HOSPITALIZATION

  1. SPEECH OR LANGUAGE PROBLEMS

  1. CHRONIC EAR INFECTIONS

  1. HEARING DIFFICULTIES

  1. EYE OR VISION PROBLEMS

  1. FINE MOTOR/HANDWRITING PROBLEMS

  1. GROSS MOTOR DIFFICULTIES/CLUMSINESS

  1. APPETITE PROBLEMS

  1. SLEEP PROBLEMS

  1. SOILING PROBLEMS

  1. WETTING PROBLEMS

  1. OTHER HEALTH DIFFICULTIES: PLEASE DESCRIBE
25. LIST CURRENT MEDICATIONS:
26. PREVIOUS THERAPY: PLEASE LIST

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