CHILDREN S HISTORY FORM

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Marilyn Norman
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1 NEUROPSYCHOLOGY ASSOCIATES, P.C N. 7TH ST., STE 100 Phoenix, Arizona Office (602) Fax (602) CHILDREN S HISTORY FORM INSTRUCTIONS TO PARENTS: Please complete this form and return it to us before your s appointment. Fill out the form to the best of your knowledge. If some questions are not applicable to your, write NA. If you need more space or wish to make any additional comments, please attach a separate sheet. Name of person filling out this form: Relationship to : Date: Child s Name: Birth date: Referred by: Phone: Reason for Consultation (What are the main questions you would like answered?) Pediatrician:_ Phone: If you would like a copy of the report to go to your 's pediatrician, please list the doctor's address here. Current School:_ Grade:

2 Page 2 FAMILY HISTORY (List parents first, then ren in birth order) father step-father mother step-mother NAME check if living in the home AGE OCCUPATION EDUCATION/ GRADE Are there significant marital conflicts? Yes _ No _ Are there significant conflicts between and parent? Yes _ No Are there significant conflicts between your ren? Yes _ No _ Do parents agree on how to discipline your? Yes _ No _ Who disciplines and how? How does your respond to discipline? PREGNANCY: Is this adopted? No _ Yes _ Did you have any of the following complications during this pregnancy? If so, indicate which month. Anemia _ High Blood Pressure _ Swollen Ankles _ Kidney Disease _ Heart Disease _ German Measles _ Toxemia _ Staining _ Bleeding _ Vomiting _ Virus _ Threatened miscarriage/early contractions _ Rh or other blood incompatibility_ List any other complications you may have had: List any chronic illness (s) such as diabetes, kidney infection, thyroid problem, etc. you were suffering from during pregnancy: _ List any other illnesses suffered during this pregnancy: List any hospitalizations during this pregnancy (date and reason): List any surgeries during this pregnancy: List any Injuries suffered during this pregnancy: List any medications taken during this pregnancy:

3 Page 3 BIRTH HISTORY OF THIS CHILD: Name of hospital: Hours from first contraction to birth: List any medication (s) administered and why: Name any anesthesia administered during birth: Was labor induced? Yes No If yes, how and why? Was your baby born head first? Yes _ No _ Don t Know _ Were forceps used? Yes _ No _ Don't know _ If yes, why?: _ Did you have a cesarean section? Yes _ No _ If yes, why? _ Did your baby have any bruises? Yes _ No _ If yes, where? Did your baby have any birthmarks: Yes _ No If yes, where? Was this a multiple birth? Yes _ No _ If yes, how many? Did your baby have breathing problems? Yes _ No _ Don know _ Was the cord around the neck? Yes _ No _ Don t know Did your baby cry quickly? Yes _ No _ Don t know Was your baby s color normal? Yes No Don t know Blue? Yellow? If your baby s color was yellow (jaundiced), did he/she receive any of the following? Oxygen Yes No How long Transfusions Yes No How many Phototherapy Yes No How long Were there any other complications before you took your baby home? Yes No If yes, what Was your baby placed in an incubator or special crib? Yes No How long How long after birth did you take your baby home? EARLY HISTORY: General: Did your baby have feeding problems? Yes No If yes, describe them Was your baby colicky? Yes No How long Did your baby require formula changes? Yes No If yes, describe them _ Did your baby have difficulty as an infant with the following? Sucking Chewing Drooling past 2 ½ months Was your baby normally active? Yes No Was your baby limp? Yes No Was your baby stiff? Yes No Did your baby show unusual trembling? Yes No If so, when_ As an infant or a toddler did your have poor muscle control (i.e., weakness)? Yes No If yes, which of the following: Neck, Trunk, Legs Chest, Arms, Fingers Did your baby fail to grow normally? Yes No Did your baby fail to gain weight? Yes No Was this baby different in any way from his/her siblings? Yes No Describe how

4 Page 4 Toileting: Indicate your 's development by circling one description. Toilet trained Early Average (13-36 mos.) Late Did your have enuresis (bedwetting)? Yes _ No _ If so, at what age did it start? Age it was controlled:. Did your have urine accidents during the day? Yes _ No _ Did your have soiling? Yes _ No _ Motor Milestones: At what age did your : Sit alone Pedal tricycle Swim.._ Tie shoes Ride bicycle Walk without holding on Dress self Feed self Which hand does your prefer? Right _ Left _ Age established _ Does your switch hands? Yes _ No Indicate your 's development by circling one description. Crawled early Early Average (6-9 mos.) Late Walked alone (2-3 steps) Early Average (9-18 mos.) Late Language Milestones: At what age did your : Speak first words Put 2-3 words together Sentence structure Speech problems? Yes No If yes, describe Indicate your 's development by circling one description. Followed simple commands Early Average (12-18 mos.) Late Used singles words/sentences Early Average (12-24 mos.) Late MEDICAL HISTORY What is your 's height? _ft. in. Weight? _ lb. Has your ever had high or prolonged fevers? Yes _ No _ Did your have frequent ear infections? Yes _ No If yes, were tubes placed? Yes _ No Does your have any visual defects? Yes No _ Does your have any hearing defects? Yes _ No _ Has your broken any bones? Yes _ No _ Does your frequently complain of any of the following: Headache _ Stomachaches _ Trouble with vision _ Dizziness _ Chronic constipation _ Weakness _ Chronic diarrhea _ Nausea _ Trouble with hearing _ Has your ever had a temperature of 104 (40 o C) or higher for more than a few hours? Yes No If yes, what age or ages? _ How long did it last? Did your ever have a seizure due to a fever or unknown cause? Yes No If yes, describe (age, nature of the seizure). Did your ever eat paint, paper, etc.? Yes _ No Has your ever accidentally swallowed any poison, drug, or non-food object? Yes No If yes, what age (s)? _ Describe

5 Page 5 Has your ever participated in team sports or other competitive sports? Yes No If yes, which ones? Has your ever been dazed ( dinged, bell rung ) or knocked unconscious while involved in sports? Yes No If yes, please describe Has your ever suffered a brain injury in an accident or assault? Yes No If yes, please describe What time does your typically go to bed? What time does your typically arise? _ Does your have any trouble falling asleep? Yes No Does your have any trouble staying asleep throughout the night? Yes No Does your sleepwalk? Yes No Does your snore? Yes No Does your have trouble with excessive movement when sleeping, such as restless legs? Yes No Does your have trouble with nightmares? Yes No Please check the following diseases and/or conditions that your has had: _ Anemia _ Encephalitis _ Metabolic disorder _ Asthma _ Enzyme deficiency _ Mumps _ Bleeding disorder _ Genetic disorder _ Oxygen deprivation _ Blood disorder _ Heart disorder _ Pneumonia _ Brain stroke _ Jaundice _ Rheumatic fever _ Broken bones _ Kidney disorder _ Scarlet fever _ Cancer _ Leukemia _ Tuberculosis _ Chicken pox _ Lung disorder _ Whooping cough _ Colds (excessive) _ Measles _ Other problems What therapies have been provided to your? No therapies Occupational therapy Physical therapy Psychological therapy (counseling) Cognitive rehabilitation services Speech therapy Chiropractic treatment Vision therapy Biofeedback Homeopathic treatments Did anyone in your immediate family or other relative have any of the following? If so, who? Problems similar to your Yes _ No _ Who Neurological disease Yes _ No _ Who Seizures (epilepsy) Yes _ No _ Who Emotional problems Yes _ No _ Who Mental retardation Yes _ No _ Who Hyperactivity Yes _ No _ Who Learning problems Yes _ No _ Who Reading or spelling difficulties Yes _ No _ Who Speech or language problems Yes _ No _ Who Does any disease run in the family? Yes _ No _ If yes, what? _

6 Page 6 MEDICATION HISTORY: List any medications your is currently taking (including dosage and reason): List any medications that your has taken in the past for more than a month (including dosage and reason): _ Has your ever had a bad reaction to any medication? Yes No If yes, describe. SCHOOL HISTORY: Does your like school? Yes _ No _ Did your attend nursery school or a preschool program? Yes _ No If yes, age started. Were there any problems? Yes _ No _ If yes, describe: Did your attend 1 st grade? Yes _ No _ If yes, age started: Were there any problems? Yes _ No _ If yes, describe: Has the school currently reported problems with: Reading _ Spelling _ Following directions _ Arithmetic _ Behavior _ Social adjustment _ Attention span_ Writing _ Has any psychological testing been done at school? Yes No _ If so, where, when and by whom? What recommendations were made? _ Has your ever been held back or repeated a grade? If yes, which grade (s) and for what reason? _ Does your receive any special services in school (placement in special classroom, resource room, tutoring, remedial reading, OT, speech, reading services, etc.)? Yes _ No _ If yes, what services and for how long? If not now, has your ever been in a special class or provided with special services under an IEP or 504? Yes No If yes, describe. Have you obtained any academic help privately for your? Yes _ No _ If yes, indicate what type, when, by whom and how often: What grades has your mostly received in the past year? A's & B's B's & C's C's & D's D's & F's Outstanding Good Satisfactory Improvement needed Unsatisfactory Are these grades changed from the previous years? Yes No In which subject does your do best? Have the most difficulty? In the past year has your been absent from school due to illness or injury? Less than 2 weeks 2-4 weeks 5-8 weeks Over 8 weeks Briefly describe the reasons for your 's absence. _

7 Page 7 BEHAVIOR AND SOCIAL HISTORY: Does your have difficulty getting along with ren his/her own age? Yes No _ Does your have difficulty getting along with adults? Yes No Does your have problems making friends in school? Yes No Does your have problems getting along with teachers? Yes No Does your tend to get sick in the morning before school? Yes No Does your get disciplined frequently at school? Yes No How does your occupy his/her time? How does your perform athletically? Has your had emotional, adjustment, or behavioral problems? Yes _ No _ Has your received any psychological or psychiatric treatment? Yes _ No _ If yes, when, where and by whom? ******************************************************************************************************************* In addition to this history form, the additional information which was requested during the initial telephone conversation would also be helpful. This includes your s birth and medical records if relevant; and preschool and/or school records, including evaluation reports by school personnel. If your has had any evaluations outside of the school, we would appreciate copies of those, as well. Additional comments:

CASE HISTORY FORM Psychologist

STUDENT SERVICES - Living Sky School Division #202 509 Pioneer Avenue North Battleford, Sask. S9A 4A5 Phone: (306) 937-7963 Fax: (306) 445-2912 CASE HISTORY FORM Psychologist Date: Person completing form: