Developmental & B... | Dr. Lynn Schiller

Names | Gender | Dates of birth

Please elaborate on any checked items above

If you answered yes above, please describe the biological mother's pregnancy (include any complications)

Other | How Often?

Please describe your labor and delivery (complications, medications, etc.)

Describe your child's condition at birth (height, weight, APGAR scores, etc.)

Describe your child as an infant (easy,difficult, etc.)

Response to touch and cuddling

Eating behaviors

Was child colicky?

Sleeping behaviors / routine (including naps and nighttime)

Describe how alert your infant was

Was your infant sociable with others, fearful of others?

Was it easy to set and follow routines with your child as an infant?

Describe your infant's activity level as an infant/toddler

Describe any health problems during infancy

Describe your child as a toddler (easy or difficult, energetic, inquisitive, defiant, independent, clingy)

Describe your child's speech and language

Describe any developmental concerns

Describe your child's general health

Does your child have any hearing or vision problems (if so please describe)

Describe your child's gross (running, biking, sports) and fine (writing,tying shoes, handling small objects) motor coordination

Does your child have any chronic health problems (Asthma, diabetes, heart condition?)

Other | What Age?

Has your child received his/her vaccinations/immunizations?

Describe any accidents or falls your child has had

Describe any hospitalizations or surgeries your child has had

At what age did your child start kindergarten?

Was he/she in daycare? If so from what ages?

Has your child ever skipped grades? If yes, which ones?

In the spaces below describe your child’s adjustment to school, interests in school, and any strengths or weaknesses.

Please note the name of the school and years the child attended the following : Preschool:

Kindergarten:

Grades 1 - 3:

Grades 4 - 6:

Junior High School:

High School:

Describe any academic subjects that are difficult for your child

Was a classification recommended or were any accommodations made?

If yes what were they?

Describe what your child is like at home (activity level, behavior, ability to entertain self, relationships)

How easily does your child make friends?

Do these friendships last?

Does your child have many friends?

Are they the same age or younger?

How well does your child get along with his/her friends?

What are your child’s interests and hobbies? Any special skills? Sports?

What were the presenting problems?

What was the outcome of treatment?

Describe the primary concerns that led you to treatment for your child at this time

When did these issues begin and how severe are the problems?

Have there been any important events (divorce, death, illnesses, accidents) in your family that may be affecting your child’s emotional health or school performance?

If so how would he/she describe the problem?

When you need to set limits with your child or when he/she does not follow the rules, what intervention strategies have you found to be effective?

Do you have concerns about alcohol or drug use with your child?

Any concerns about eating disorders with your child?

What would be the most difficult adjustment in your child’s life to date?

L S

Clinical Psychologist

LYNN SCHILLER, Ph.D

DEVELOPMENTAL HISTORY & BACKGROUND

FAMILY MEMBERS

SIBLINGS

OTHERS LIVING IN THE HOUSEHOLD

FAMILY MEDICAL HISTORY

PREGNANCY

PREGNANCY QUESTIONS

CHILD'S INFANCY

LANGUAGE DEVELOPMENT

MEDICAL HISTORY

SCHOOL HISTORY

SOCIAL DEVELOPMENT

TREATMENT HISTORY

CURRENT CONCERNS

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