DEVELOPMENTAL HISTORY

To be completed on all children 17 years old and younger

Name of Child:________________________    ID# __________   DOB:________
Informant: ___________________________   Relationship:__________________
Mother’s health during pregnancy: Good ____      Fair_____     Poor______
Any illness/complications during pregnancy?(ex. R.H. neg. toxemia, diabetes)
___________________________________________________________________
Any substance abuse before or during pregnancy? (Specify) _________________
___________________________________________________________________

Delivery:
Length of pregnancy: ______months                   Labor:_____ hours
Type of delivery: Vaginal:___     Cesarean:___    Birth Weight:_________
Complications (if any) _______________________________________________
Child’s condition after birth ___________________________________________

Early Development:
Walked: __________(age)             Difficulties?  ____________________________
First word spoken: ______(age)     Difficulties? ____________________________
Sentences formulated: _____(age) Difficulties? ____________________________
Toilet trained:________ (age)         Difficulties? ____________________________
Any unusual childhood illnesses? ________________________________________
Child raised by natural parents? yes/no (specify) ___________________________
If parents separated or divorced what are the legal custody arrangements? ______
____________________________________________________________________
Any child care arrangements? ex: Baby-sitter, daycare _______________________
Any child care difficulties? ______________________________________________
Any long separation from the primary care giver?  __________________________
Any social/behavioral problems? (specify) _________________________________
Child’s present grade? ____   Any school problems? _________________________
Describe child’s temperament? __________________________________________
____________________________________________________________________

___/___/_____                                                     _____________________________  
     Date                                                                          Parent/Guardian Signature

Solutions Counseling & Consultation Services 35 E. Elizabeth Ave. Suite 37 Bethlehem PA  18018 Phone (610) 865-1303  *  Fax (610) 865-9632

w:l/develop rev. 6/98