developmental history - elizabethfbaumann.com€¦ · web viewwhat concerns do you have about...
TRANSCRIPT
PARENT QUESTIONNAIRE
IDENTIFYING INFORMATION
Child’s name
Age DOB Sex (circle one)
M F
Grade
Or Highest level of education
School
Address State
Zip
PARENT
Address State
Zip
Home
Elizabeth F. Baumann, Ph.D.1218 Massachusetts Avenue, 3rd Floor
Cambridge, MA 01238617-209-9934
phone
Work phone
Occupation
Highest level of education
PARENT
Address State
Zip
Home phone
Work phone
Occupation
Highest level of education
PARENTAL RELATIONSHIP (ie married, divorced, etc.)
Address to send report:
What strengths do you see your child as having?
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SCHOOL INFORMATION
Name of school:
Address: Phone:
Grade Middle High College Post Voc/tech
Other:
School School School Graduate
Grade: Repeated grade? YES NO Which grade?
Academic grades received:
What concerns do you have about your child’s learning?
What concerns do you have about your child’s emotional or behavioral functioning at school?
What concerns do you have about your child’s social functioning at school?
Has your child been diagnosis with a learning disability? NO YES If yes, by whom
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SCHOOL INFORMATION (continued)SUPPORT SERVICES
Currently on IEP or 504 NO YES If yes, which
When did IEP/504 begin?
Describe support services your child receives at school?
Counseling at school? NO YES
Tutoring outside of school? NO YES If yes, describe
HOMEWORKHow long does homework take?
Do you have concerns about homework?
How does homework get done?
Independence:
Organization:
Does child bring home materials, know assignments and return homework to school?
STRENGTHSWhat strengths do you see your child as having academically?
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SCHOOL INFORMATION (continued)EVALUATIONS PERFORMED AT OR OUTSIDE OF SCHOOL
Date/grade Type Reason Results
SCHOOL HISTORY
Grade Name of schoolAcademicproblems
Behavioral problems
Supports504 or
IEP
Pre-K
K
1ST
2ND
3RD
4TH
5TH
6TH
7TH
8TH
9TH
10TH
11TH
12TH
College
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MENTAL HEALTH HISTORY
Has your child received a psychiatric diagnosis by a doctor?
If yes, please explain:
Are there current difficulties your child is experiencing that you are concerned about?
If yes, please explain:
Is your child seeing a counselor?
Who:Did you send them our form to fill out? YES NO
What problems is the counselor helping with?
Has your child seen a counselor in the past? NO YES
If yes, for what problems/issues?
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MENTAL HEALTH HISTORY
Is your child taking medications for any psychiatric difficulties?
NO YES
Who prescribes the medication?
CURRENT PSYCHIATRIC MEDICATIONS:Medication name Dates Helpfulness
PREVIOUS PSYCHIATRIC MEDICATIONS:Medication name Dates Helpfulness
OTHER TREATMENT:Dates Name of professional
Family therapyBehavior therapyOtherOther
PAST PSYCHIATRIC HISTORY:Note any hospitalizations or other treatments not included above:
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DEVELOPMENTAL HISTORY
ADOPTION:
Was your child adopted? NO YES At what age?
If yes, how much developmental information is known?
PRENATAL HISTORY:During pregnancy . . .
Were drugs used? NO YES If yes, describe
Was alcohol used? NO YES If yes, describe
Smoked? NO YES If yes, describe
Full term? NO YES If no, describe
Mother had diabetes, toxemia, eclampsia YES NOIf yes, describe
Did the mother have high blood pressure? YES NO
PERINATAL HISTORY:
Normal delivery? YES NO If no, describeWas birth vaginal or cesarean? (circle one) Birth weight?Was the mother induced with pitocin? YES NOWere there any birth complications? YES NOIf yes, describe
Did baby have trouble starting to breathe? YES NOHealthy? YES NOIf no, describe
Did baby require time in the NICU? YES NOIf yes, describe
Do you know child’s apgar score? YES NO Score:10
DEVELOPMENTAL HISTORY (continued)
POSTNATAL HISTORY:Was baby breast fed/ bottle-fed? How long?Did baby gain weight adequately? YES NOIf no, describe
Were there problems in the first week? YES NOIf yes, describe
Birth order of this baby?
CHECK ALL THAT APPLY TO YOUR CHILD AS AN INFANTActiveActive but calmPassiveOther:
CuddlyIrritableWithdrawnOther:
Cried easily and frequentlyCried a reasonable amountCried seldomOther:
Soothed easilySoothed with difficultySoothed with average amountOther:
Severe response to changesModerate response to changesMild response to changes
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Other:
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DEVELOPMENTAL HISTORY (continued)
Friendly reaction to strangersIndifferent reaction to strangersFearful reaction to strangersOther:
Startled easilyNot startled easily
MILESTONES: Note age when first achieved.
MOTOR AVERAGE CHILDRolled front to back 4 MosSat with support 6 MosSat alone 9-10 MosPulled to stand 10 MosCrawled 10-12 MosWalked alone 10-18 MosRan 15-24 MosUsed tricycle 3 YrsUsed bicycle 5-7 Yrs
LANGUAGE AVERAGE CHILDSmiled 4-6 WksCooed 3 MosBabbled 6 MosUsed jargon 10-14 MosSaid first word 12 MosUsed 2 word combo 22 MosUsed 3 word sentence 3 Yrs
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DEVELOPMENTAL HISTORY (continued)
Describe history of speech, language or motor problems if any
Were early intervention services provided? If so for what?
ADAPTIVE AVERAGE CHILDPicked up small objects 11-12 MosScribbled 15 MosUsed cup 10 MosUsed spoon 12-15 MosFollowed 1-step commands 15 MosDressed / washed handsBladder trainedBowel trained
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MEDICAL HISTORY
Current medical problems:
Does your child take any medications for medical problems? NO YESIf yes, please list
PAST MEDICAL HISTORY:Include dates
Hospitalizations:
Major surgeries:
Neurological consultations:
SUBSTANCE USE (if applicable)Smoke cigarettes? NO YES If yes, how many?Drink alcohol? NO YES If yes, how much?Other substances? NO YES If yes, describe:
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MEDICAL HISTORY (continued)CHECK ALL THAT APPLY
DATES
Head injury causing loss of consciousness
Seizures/convulsions
Other nervous system problems
Ear, nose or throat problems
Dental problems
Asthma
Other chest problems
Stomach or bowel problems
Urinary or bladder problems
Wetting or soiling
Rheumatic fever
Heart problems
Liver/kidney problems
Skin problems
Joint/limb problems
Hearing/vision problems
Growth problems
Serious accidents/fractures
Childhood measles/mumps/chicken pox
Sensory integration problems
Other:
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FAMILY ENVIRONMENT
Note immediate family members living at homeADULTSName
Age
Relationship
Occupation
Name
Age
Relationship
Occupation
Name
Age
Relationship
Occupation
Name
Age
Relationship
Occupation
CHILDRENName
Age Relationship
School grade
Name
Age Relationship
School grade
Name
Age Relationship
School grade
Name
Age Relationship
School grade
Name
Age Relationship
School grade
Name
Age Relationship
School grade
Name
Age Relationship
School grade
Name
Age Relationship
School grade
Note immediate family members not living at homeADULTS / CHILDREN
Name
Age
Relationship
Whereabouts
Name
Age
Relationship
Whereabouts
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FAMILY HISTORY
PSYCHIATRIC HISTORY OF BIOLOGICAL FAMILY (if known):Check all that apply
Learning disabilityFamily member:
HyperactivityFamily member:
Attention deficitFamily member:
AnxietyFamily member:
PanicFamily member:
Obsessions / compulsionsFamily member:
RitualsFamily member:
DepressionFamily member:
ManiaFamily member:
Suicidal thoughts/ urges/ actionsFamily member:
Coordination problemsFamily member:
Unusual noises / vocalizationsFamily member:
Movement disorderFamily member:
TicsFamily member:
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FAMILY HISTORY (continued)
PSYCHIATRIC HISTORY OF BIOLOGICAL FAMILY (If known):Check all that apply
Mental retardationFamily member:
Autism/ PDDFamily member:
PsychosisFamily member:
Psychiatric hospitalizationsFamily member:
Substance abuse:Family member:
Other:Family member:
Other:Family member:
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