NC-5

Developmental History

Child’s Name: ______

DOB______Age______

Parent(s)/Guardian(s) Name: ______

Address: ______

Phone ______Email______

Best time and way to contact you: ______

Pregnancy and Birth

Gestation: Full term Premature (how many weeks?)______Delivery: Vaginal C-Section: elective / emergency
Birth Weight: ______lbs ______oz
Complications during pregnancy?__yes __no(if yes, please circle and/or explain)
vaginal bleeding infection toxemia hypertension trauma other (list)
Special Considerations at birth? __yes __no (if yes, please circle and/or explain)
jaundice twin/multiple NICU oxygen tube feedings other (list)

Developmental History

Does your child respond to sounds/voice? _____yes ______no
Does your child respond to name? _____yes ______no
Does your child make eye contact with others? __yes __no
Number of words that are understandable ______
How does your child indicate wants?
How does your child learn new things and problem solve? / Please List Specific Concerns
Age at milestones:
Sitting ______Crawling ______Walking ______
Gross Motor: How does your child get around in his/her environment?
Fine Motor:How does your child manipulate objects/use hands? / Please List Specific Concerns
Behaviors/Behavioral concerns? __yes __no If yes, please explain:
Does your child perform daily living skills (i.e. dressing self, cares for own toileting needs, feeds self, etc)? __yes __no
Do you have feeding or nutritional concerns? __yes __no / Please List Specific Concerns

Health

Does your child have any health concerns or diagnoses?
__yes __no If yes, please explain:
Is the child working with other specialists? __yes __no
If yes, please list:
Does your child have difficulty sleeping? __yes __no
If yes, please explain: / Is your child currently taking medications? __yes __no
If yes, please list:
Has your child been hospitalized since birth? __yes __no
If yes, please explain:
Does your child have any allergies? __yes __no
If yes, please list:
Hearing
Do you have any concerns with your child’s hearing?
__yes __no
Has the child’s hearing ever been screened/tested?
__yes __ no When?
Has your child had frequent ear infections? __yes __ no
Has your child had tubes placed in his or her ears?
__yes __no When? / Vision
Do you have any concerns with your child’s vision?
__yes __no
Has the child’s vision ever been screened? __yes __ no
When?

Parent

What are some of the biggest challenges for you with your child?
Does your child go to day care? ___yes ___no Daycare contact information
Where/When:
Does your child nap? ___yes ___no If yes, in general, for how long?

06-09