Developmental History

/ Melissa M. Mohlman, Ph.D.
Westlake Psychological Services, PLLC
1301 S. Capital of Texas Highway, Suite C-130
Austin, Texas 78746
Phone: 512-917-1307 Fax: 512-306-9234

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DEVELOPMENTAL HISTORY

Patient's Name: ______Age: ______

FAMILY COMPOSITION

Individuals Living in Household

(Please include step-parents, roommates, partners) Parents or Siblings Outside of Household

Name Age Relationship Name Age Relationship

______

Length of time in current residence? ______

Parents' Current Marital Status _____ Number of Marriages of Mother______Number of Marriages of Father ______

If divorced, please describe custody and visitation arrangements: ______

______

Father’s Occupation ______Place of Employment ______

Mother’s Occupation ______Place of Employment ______

PRESENTING PROBLEM:

What caused you to seek help? ______

______

Did anything happen at the same time that may have caused the problem? Yes _____ No _____

If yes, please explain: ______

______

MEDICAL AND DEVELOPMENTAL HISTORY

This is a very important section of our study of your child. The information you furnish is held in confidence. Please answer in the blanks provided.

Was child adopted? _____ If so, at what age? _____

Current Medical Problems? ______

Primary Care Physician, Pediatrician or Family Physician______

Date last seen: ______

MEDICAL HISTORY

Current Past Current Past

Meningitis or encephalitis? ______Several High Fevers? ______

Head injury? ______Weakness? ______

Frequent ear infections? ______Vision problems? ______

Tubes placed? ______Diabetes? ______

Hearing difficulties? ______Episodes of unconsciousness? ______

Speech difficulties? ______Cancer? ______

Allergies? ______Muscle pain? ______

Seizures? ______Surgery? ______

Blank spells? ______Headaches? ______

Dizziness? ______Stomachaches? ______

Nausea? ______Ulcers? ______

Heart Disease? ______Blood Pressure Disease? ______

Hormonal (Thyroid) Disease? ______Hospitalizations? ______

Please explain any ‘yes’ answers: ______

Present Medications (Names and Dosage): ______

______

Please list family members (parents, grandparents, siblings, aunts, uncles) who have ever had any of the following problems:

Mother’s Side Father’s Side

ADHD (attention problems/hyperactivity) ______

Learning Disorder ______

Depression/Suicide ______

Anxiety/Excessive Worry ______

Obsessive Compulsive symptoms

(e.g. excessive handwashing, checking,

performing rituals) ______

Panic Attacks ______

Alcohol/Drug Use ______

Schizophrenia ______

Bipolar Disorder (Manic Depression) ______

Problems with the Law ______

History of Seizures ______

PREGNANCY HISTORY

1) List medications taken during pregnancy: ______

2) Check any of the following that were present during your pregnancy with this child:

High blood pressure _____ Use of nonprescription drugs _____ Alcohol consumption _____

Tobacco Use _____ Nausea _____ Headaches _____ Accidents _____ Swelling _____

Infections _____ Convulsions _____ Diabetes _____ Anemia _____ Vomiting _____

3) Length of pregnancy ______

4) Describe any complications during delivery of child: ______

INFANCY AND EARLY CHILDHOOD

1) From birth to age three who was the child's primary caretaker?

______

2) Were there periods when the primary caretaker was away from the child? ______

If yes, for how long? ______

Who cared for child during those times? ______

3) Did the primary caretaker experience any of these significant difficulties during this period?

(Check all that apply)

Extended Illness _____ Loss of own parent _____ Chemical Dependency_____ Hospitalization _____ Baby Blues_____

Divorce/Separation_____ Financial stressors _____ Frequent moves _____ Depression _____ Spousal Abuse _____

4) If the primary caretaker worked outside of the home, how many different child care settings was the child in?

______

5) Was the child a cuddly baby? ______Irritable baby? ______

6) At what age did your child?

Sit Alone ______Crawl ______Walk ______Speak single words ______Speak several words together ______

7) Which best describes your child's development? _____ Slow _____ Fast _____ Normal

8) What is your opinion of your child's intelligence? ____ Average ____Below Average ____Above Average

9) Additional Comments:______

______

10) Does your child wet the bed or pants? ______How often? ______

11) Does your child soil his/her pants? ______How often? ______

12) Has your child ever been weaker _____ or stronger _____ than others?

13) Has your child ever had: _____Seizures/Convulsions _____Head Injuries _____Memory Problems

_____Coordination Problems

SEXUAL DEVELOPMENT

1) Is your child’s sexual development early ______or delayed ______? If so, describe: ______

______

2) Have there been problems in the sexual adjustment of the child? ______

If yes, please explain? ______

3) Has child been sexually abused? ______

If yes, when______by whom? ______

Has this been reported to CPS or law enforcement? ______

DISCIPLINE

1) Child is most often disciplined by whom? ______

2) Discipline most effective with the child ______

3) Discipline least effective with the child ______

4) Do parents agree on how to discipline? Yes ______No ______

5) Has child ever been physically abused? ______

If yes, when ? ______by whom? ______

Has this been reported to CPS or law enforcement? ______

SOCIAL DEVELOPMENT

1) Does the child have problems relating with: (check all that apply)

Children of own age?______Teachers? ______Brothers/Sisters?______Parents? ______Other adults? ______

2) Has the child been a victim of peer teasing or bullying? Yes ___ No ___

3) Does the child like to play with children: (check all that apply)Own Age? _____ Younger? ______Older? ______

4) Does child have: (check all that apply) Many friends? ______Few friends? ______No friends? ______

5) Is the child a: (check all that apply) Leader? ______Follower? ______Loner? ______

6) Has the child ever had problems involving the police or juvenile authorities? ______

If yes, when ______What? ______

7) Do you have any concerns about alcohol or drug use by your child? ______

If yes, briefly explain ______

SCHOOL HISTORY

1) Name of present school: ______Grade ______

2) Is the child in Special Education? ______

If yes, which service:

Resource? ______Content Mastery ? ______Behavior Improvement? ______ECI? ______Alternative School? ______

3) Has the child ever repeated a grade? ______If yes, what grade(s)? ______

4) Is your child currently experiencing academic or behavioral difficulties in school?______

If yes, briefly explain ______

______

FAMILY PROBLEMS WHICH MAY BE AFFECTING YOUR CHILD

______Recent or multiple moves ______Custody dispute

______Parental separation or divorce ______Financial stresses

______Family violence ______Health problems

______Conflict between parents ______Psychiatric illness

______Drug or alcohol abuse ______Death in the family

______Remarriage or new partner ______Absence of parent

OTHER TREATMENT

Has your child had previous counseling? ______Psychological Testing? ______

Medication for emotional or behavioral problems? ______

If yes, what agency or individual treated him/her? ______

______

Signature of person completing form Relationship to child Date

PEDIATRIC SYMPTOM CHECKLIST

Never Sometimes Often

1. Complains of aches and pains ______

2. Spends more time alone ______

3. Tires easily, little energy ______

4. Fidgety, unable to sit still ______

5. Has trouble with a teacher ______

6. Less interested in school ______

7. Acts as if driven by a motor ______

8. Daydreams too much ______

9. Distracted easily ______

10. Is afraid of new situations ______

11. Feels sad, unhappy ______

12. Is irritable, angry ______

13. Feels hopeless ______

14. Has trouble concentrating ______

15. Less interest in friends ______

16. Fights with other children ______

17. Absent from school ______

18. School grades dropping ______

19. Is down on him or herself ______

20. Visits doctor with doctor finding nothing wrong ______

21. Has trouble with sleeping ______

22. Worries a lot ______

23. Wants to be with you more often than before ______

24. Feels he or she is bad ______

25. Takes unnecessary risks ______

26. Gets hurt frequently ______

27. Seems to having less fun ______

28. Acts younger than children his or her age ______

29. Does not listen to rules ______

30. Does not show feelings ______

31. Does not understand other people’s feelings ______

32. Teases others ______

33. Blames others for his or her troubles ______

34. Takes things that do not belong to him or her ______

35. Refuses to share ______

Comments: ______