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Childhood Disabilities: Early Identification and Intervention

CHILD'S HISTORY and FAMILY BACKGROUND

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 child is living with:

• Maternal Guardian's Name:
• Occupation:
• Work Phone:

• Paternal Guardian's Name:
• Occupation:
• Work Phone:

• Name:
• Address:
• Phone:

• 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):

• Spontaneous
• Induced - duration of hours:

• Normal
• Breech
• Caesarean

• Cord around neck
• Hemorrhage
• Infant injured during delivery
• Infant positive for cocaine or other substance (specify):

• Jaundice
• Cyanosis (turned blue)
• Intensive Care Nursery
• Infection (specify):
• Cerebral bleed
• Other health complications after birth (specify): ____________

• 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

COORDINATION Check appropriate box that is true for your child

What type of physical activities does your child engage in?

MEDICAL HISTORY: Check appropriate box for your child:

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:

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:

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:

Check the box which best describes your child:

Check the box which best describes your child's current behaviors:

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 treating professionals to have a more complete understanding of who your child is.

Coping.org is a Public Service of James J. Messina, Ph.D. & Constance M. Messina, Ph.D.,  Email: jjmess@tampabay.rr.com  ©1999-2007 James J. Messina, Ph.D. & Constance Messina, Ph.D.  Note: Original materials on this site may be reproduced for your personal, educational, or noncommercial use as long as you credit the authors and website.