| CHILD's HISTORY and FAMILY BACKGROUND |
7. Child's History and Family Background Reporting Form
Tools for Early Identification and Intervention- 0-5 years
By James J. Messina, Ph.D.
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CHILD'S HISTORY and FAMILY BACKGROUND REPORTING FORM
Name of Child: Date of Birth:
Parents complete this form (preferably typed out) and bring copies into all future Developmental Assessment for which your child is scheduled.
Child's Name:
Birth Date:
Age:
Sex:
Home Address:
Street:
City:
State:
Zip:
Home Phone:
Child's School's Name:
Child's Grade Level :
Adults with whom child is living:(circle which adults live with child)
Natural Mother
Natural Father
Stepmother
Stepfather
Adoptive Mother
Adoptive Father
Foster Mother
Foster Father
Other:
Non-residential adults involved with child: (circle adults involved with child)
Natural Mother
Natural Father
Stepmother
Stepfather
Adoptive Mother
Adoptive Father
Foster Mother
Foster Father
Other:
Adults child is living with:
Maternal Guardian's Name:
Occupation:
Work Phone:
Paternal Guardian's Name:
Occupation:
Work Phone:
Who referred you?
Name:
Address:
Phone:
Briefly state main problems of your child:
Check only if True for your child
PREGNANCY
_____Excessive Vomiting
_____Hospitalization Required
_____Excessive staining/ blood loss
_____Threatened miscarriage
_____Infection(s) (specify)
_____Toxemia or eclampsia
_____Operation(s) (specify)
_____Other illness(es) (specify)
_____Smoking during pregnancy and number of cigarettes per day:
_____Alcoholic consumption during pregnancy/how much consumed a day:
_____Medications taken during pregnancy (specify):
_____X-ray studies during pregnancy (specify):
Duration of pregnancy (weeks):
DELIVERY
Type of Labor:
_____Spontaneous
_____Induced - duration of hours:
Type of Delivery:
_____Normal
_____Breech
_____Caesarean
Complications:
_____Cord around neck
_____Hemorrhage
_____Infant injured during delivery
_____Infant positive for cocaine or other substance (specify):
Birth weight:__________
POST DELIVERY PERIOD
Jaundice
Cyanosis (turned blue)
Intensive Care Nursery
Infection (specify):
Cerebral bleed
Other health complications after birth (specify): ____________
How many days was infant in Hospital after delivery:________
INFANCY PERIOD (Birth - 18 months) and TODDLER PERIOD (18 months - 3 Years)
_____Easy baby
_____Average baby
_____Difficult baby
_____Very active as infant and toddler
_____Average level of activity as infant and toddler
_____Not active as infant and toddler
_____Feeding problems
_____Enjoyed cuddling
_____Was not calmed by being held or stroked
_____Colicky
_____Sleep pattern difficulties and/or diminished sleep
_____Excessive restlessness
_____Problems with responsiveness and alertness
_____Head banging
_____Experienced health problems during this period of life
_____Had any congenital problems
_____Diagnosed as having the following disability or condition:
_____Constantly into everything
_____Excessive number of accidents compared to other children
_____More sociable than others
_____Average sociability
_____More unsociable than others
_____Very insistent when wanted something
_____Average insistent when wanted something
_____Not at all insistent when wanted something
DEVELOPMENTAL MILESTONES Check appropriate box that is True for your child
Milestone
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Early accomplish
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Normal accomplish
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Late accomplish
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smiled
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sat without support
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crawled
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stood without support
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walked without assistance
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spoke first words
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said phrases
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said sentences
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bladder trained, day
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bladder trained, night
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bowel trained , day
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bowel trained, night
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rode tricycle
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rode bicycle (without training wheels)
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buttoned clothing
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tied shoelaces
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named colors
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counted to 10
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named coins
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said alphabet in order
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began to read
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COORDINATION Check appropriate box that is true for your child
Motor skill
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Good
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Average
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Fair
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walking
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running
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throwing
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catching
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shoelace tying
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writing
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athletic ability
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What type of physical activities does your child engage in?
MEDICAL HISTORY: Check appropriate box for your child:
Condition
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Good
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Fair
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Poor
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health in general
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hearing
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speech articulation
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vision
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gross motor coordination
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fine motor coordination
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Child has or has had the following:
Chronic Conditions:
_____chronic asthma
_____diabetes
_____heart condition
_____HIV/AIDS
Childhood Diseases:
_____mumps
_____chickenpox
_____measles
_____whooping cough
_____scarlet fever
_____pneumonia
_____encephalitis
_____otitis media (fluid in ear)
_____lead poisoning
_____seizures with fever
_____seizures without fever
_____coma
_____persistent high fever
_____other disease(s) (specify):
Accidents resulting in:
_____broken bones
_____severe lacerations
_____head injury
_____severe bruises
_____stomach pumped for poisoning or other (specify):
_____eye injury
_____lost teeth
_____sutures (stitches)
_____Specify number of accident(s) child has had:
Surgery for the following:
_____tonsillitis
_____adenoids
_____hernia
_____appendicitis
_____eye, ear, nose, & throat
_____digestive disorder
_____urinary tract
_____leg or arm
_____burns
_____other (specify):
_____Specify number of surgery(s) child has had:
_____Specify number of incidents child has been hospitalized to date:
Is there a history of:
_____physical abuse in family
_____sexual abuse in family
_____alcohol abuse in family
_____drug abuse in family
Has a problem currently with:
_____sleeping
_____being a restless sleeper
_____bladder control during day
_____bladder control at night
_____bowel control during day
_____bowel control at night
_____over eating
_____under eating
Child current health status:
Weight:
Height:
Being treated for:
On following medications:
FAMILY HISTORY - MOTHER
Age at time of pregnancy:
Pregnancy on mother's part was:
Planned and wanted
Unplanned but wanted
 Unplanned and unwanted
Mother's Highest grade completed:
Describe any of Mother's Learning problems:
Describe any Mother's Behavior problems:
Describe any Mother's Medical problems:
List Mother's blood relatives who experienced problems similar to what child is experiencing:
name
relationship
condition or problem
FAMILY HISTORY - FATHER
Age at time of pregnancy:
Pregnancy on father's part was:
Planned and wanted
Unplanned but wanted
Unplanned and unwanted
Father's Highest grade completed:
Describe any of Father's Learning problems:
Describe any of Father's Behavior problems:
Describe any of Father's Medical problems:
List Father's blood relatives who experienced problems similar to what child is experiencing:
name
relationship
condition or problem
CHILD"S COGNITIVE AND EDUCATIONAL BACKGROUND:
Child comprehends directions and situations as well as other children
yes
no, why not?
Child's level intelligence in comparison to other children:
below average
average
above average
SCHOOL HISTORY Rate child's school experiences:
School level
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Preschool
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Kindergarten
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Grade 1-3
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Grade 4-5
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Grade 6-8
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Grade 9-12
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Academic
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Good
Average
Poor
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Good
Average
Poor
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Good
Average
Poor
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Good
Average
Poor
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Good
Average
Poor
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Good
Average
Poor
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Socially/ Behaviorally
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Good
Average
Poor
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Good
Average
Poor
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Good
Average
Poor
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Good
Average
Poor
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Good
Average
Poor
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Good
Average
Poor
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At what grade level is your child functioning in:
Reading:
Spelling:
Arithmetic:
Has child ever had to repeat a grade?
no
yes, when?
Child is currently placed in a:
regular class
special class (specify):
Child is currently receiving special services and counseling:
no
yes (specify):
Child's teacher reports child's problem in paying attention or concentrating in:
Situations during
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No problem
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Minor problem
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Major problem
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Severe problem
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individual work times
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small groups
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free-play time in class
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lectures in class
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field trips
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special assemblies
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movies, videos, filmstrips
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class discussions
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Child's teacher describes the following as significant classroom problems:
_____does not sit still in seat
_____frequently gets up and walks around classroom
_____shouts out, does not wait to be called on
_____won't wait for personal turn
_____doesn't cooperate well in group activities
_____typically does better in a one to one relationship
_____doesn't respect the rights of others
_____doesn't pay attention during circle time, storytelling or "show and tell"
Describe your concerns about child's school performance:
SIBLING & PEER RELATIONSHIPS
Child gets along with siblings:
_____doesn't have any
_____better than average
_____average
_____worse than average
Child seeks out friendships with peers:
yes
no
Child is sought out by peers for friendship:
yes
no
How easily does the child make friends?
easier than average
average
worse than average
Child plays primarily with children who are:
same age
older
younger
Describe what problems child has with peers:
INTERESTS AND ACCOMPLISHMENTS
What are child's main hobbies or interests?
What are child's areas of greatest accomplishment?
What does child enjoy doing most?
What does child dislike the most?
HOME BEHAVIORS
Child displays the following behaviors to an excessive or exaggerated degree when compared to other children the same age:
_____hyperactivity (high activity level)
_____poor attention span
_____impulsivity (poor self control)
_____temper outbursts
_____low frustration threshold
_____sloppy table manners
_____interrupts frequently
_____doesn't listen
_____sudden outbursts of physical abuse of other children
_____acts like driven by a motor
_____wears out shoes more frequently than other siblings
_____heedless to danger
_____excessive number of accidents
_____does not learn from experience
_____poor memory
_____more active than siblings or children same age
_____a "different child"
Types of Discipline used in Home:
_____verbal reprimands
_____time out
_____removal of privileges
_____rewards
_____physical punishment
_____acquiescence to child
_____avoidance of child
_____redirection
To what extent are the two guardians in the home consistent with respect to disciplinary strategies:
_____most of the time
_____some of the time
_____none of the time
Have any of the following stress events occurred within the past 12 months?
_____parents divorced or separated
_____family accident or illness
_____death in family
_____parent changed job
_____changed schools
_____family moved
_____family financial problems
_____other (specify):
Child has problems paying attention or concentrating in any of the following:
Situations when
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No problem
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Minor problem
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Major problem
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Severe problem
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playing alone
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playing with other children
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mealtimes
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getting dressed
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watching TV
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visitors are in the home
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visiting someone else
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at church or Sunday school
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in supermarkets, stores, restaurants or other public places
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asked to do chores at home
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during conversations with others
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in the car
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father is home
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asked to do school homework
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Check the box which best describes your child:
Behavior
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Not at all
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Just a little
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Pretty much
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Very much
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often fidgets or squirms in seat
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has difficulty being seated
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is easily distracted
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has difficulty awaiting turn in groups
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often blurts out answers to questions
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has difficulty following instructions
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has difficulty sustaining attention to tasks
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often shifts from one uncompleted activity to another
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has difficulty playing quietly
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often talks excessively
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often interrupts or intrudes on others
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often does not seem to listen
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often loses things necessary for tasks
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often engages in physically dangerous activities without considering consequences
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Check the box which best describes your child's current behaviors:
Behavior
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Not true
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Somewhat true
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Very true
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fails to finish things which were started
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can't concentrate, can't pay attention for long
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can't sit still, restless, or hyperactive
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fidgets
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daydreams or gets lost in thoughts
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impulsive or acts without thinking
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difficulty following directions
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talks out of turn
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messy work
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inattentive, easily distracted
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talks too much
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fails to carry out assigned tasks
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Has child displayed any of the following:
_____stereotyped mannerisms
_____odd postures
_____excessive reaction to noise or fails to react to loud noises
_____overreacts to touch
_____compulsive rituals
_____perseveration
_____self-stimulation
_____motor tics
_____vocal tics
List child's siblings:
Name:
Age:
Developmental problems if any:
Medical problems if any:
Social problems if any:
School problems if any:
List names and addresses and telephone numbers of all professionals involved with your child or consulted concerning your concerns about the child:
Name:
Professional Title/Position:
Address:
Telephone:
Fax:
Email:
ADDITIONAL REMARKS which will help in assessing your child's needs:
Please use the back of this page to write any additional remarks you may wish to make regarding your child's difficulties.
Signed:
Parent or Guardian Name:
Date you filled it out
Please bring this completed form to your child's assessment appointment(s) or mail it to be reviewed prior to your first appointment. Taking the time to fill this form out will assist you to help your child's treatingprofessionals to have a more complete understanding of who your child is.
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