Psychological Services

Psychological testing and treatment

for Individuals, Couples, and Families.

African American Mother with Daughter
African American Boy

Developmental History/Child Adolescent

Astrid Heathcote, Psy.D.

Licensed Clinical Psychologist
10429 S. 51st Street
Suite 202, 204

Phoenix AZ 85044
480-477-8457

www.drastrid.org

 

 

Developmental History Form

 

Interviewer’s name    _____________________________________________

Child’s name   ___________________________________________________

Address   _______________________________________________________

              _______________________________________________________

School   ________________________________________________________

Teacher   _______________________________________________________

 

Date   ____________________

Birth date      _________________                             Age _________

Phone  ____________________

Grade  ________                                                      Sex     M       F

 

Person Answering Questions

Name  _________________________________________________________

Relationship to child  ______________________________________________

Address   _______________________________________________________

    _______________________________________________________

Home phone __________________       Work phone ________________

 

Referral Information

Why are you seeking help for this child?  ______________________________

          _________________________________________________________

          _________________________________________________________

Who referred you to our service?  ____________________________________

_______________________________________________________________

What kind of services are you seeking for this child?

          _________________________________________________________

          _________________________________________________________

          _________________________________________________________

          _________________________________________________________

 

Parents

Mother’s name   _______________________        Stepmother?   No      Yes

Address   ______________________________________________

Home phone   ______________________   Work phone ________________

Occupation _______________________     Employer __________________

Highest grade completed __________________________________

 

Father’s name _________________________        Stepfather?  No        Yes

Address ________________________________________________

Home phone ______________________     Work phone ________________

Occupation _______________________     Employer ___________________

Highest grade completed __________________________________

 

Does this child have other parent(s)/stepparent(s)?                        No                    Yes

If yes, provide the following information.

Name _________________________________________________________

Relationship to this child ___________________    Home phone ____________

Address _______________________________________________________

 

Name _________________________________________________________

Relationship to this child ___________________    Home phone ____________

Address ________________________________________________________

 

Family History

Is this child closer to one parent than the other?                    No        Yes

If yes, which? ____________________________________________________

Has the child ever experienced any parental separations, divorces, or death?

                                                                                             No                  Yes

If yes, when? _____________________     How old was the child? __________

Please describe the circumstances. ___________________________________

          __________________________________________________________

          __________________________________________________________

If parents are separated or divorced, who has custody of this child?

          __________________________________________________________

How often does the other parent see this child?         □ Weekly or more often

□ Once or twice a month     □ Few times a year        □ Never

 

Brothers/Sisters

Please list all brothers and sisters, and any other children living in the family.

Age

Sex

Relationship to child

Living at home?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How does this child get along with brother(s) and/or sister(s)? _____________
          _________________________________________________________

 

Child’s Residence

□ Apartment            □ Single home          □ Other _______________________

 

Family Relations

Check the activities in which this child often participates with the family.

□ Movies                 □ Meals                   □ Conversations                 □ Church

□ Games                  □ Sports                  □ Vacations/trips                □ Other

 

How frequently does the child see grandparents?

□ Weekly or more often       □Once or twice a month      □ Few times a year

                                      □ Never                     □ No grandparents living

What do you enjoy most about this child? ______________________________          __________________________________________________________

          __________________________________________________________

What do you find most difficult about raising this child? ___________________

          __________________________________________________________

          __________________________________________________________

What would you like this child to be when he/she grows up? ________________

          __________________________________________________________

What level of education do you hope this child will complete?    

          □ High school           □ Technical/vocational school         □ College

Who is mainly in charge of discipline in the home? ________________________

Do all caregivers agree on discipline? __________________________________

Describe discipline techniques. _______________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

 

Pregnancy

Check any of the following complications that occurred during the pregnancy.

     □ Difficulty in conception      □ Toxemia                    □ Abnormal weight gain

     □ Measles                         □ Excessive vomiting      □ Excessive swelling

     □ Emotional problems           □ Vaginal bleeding          □ Flu

     □ Anemia                          □ High blood pressure     □ Other

     □ Maternal injury: _______________________________________________

     □ Hospitalization during pregnancy: _________________________________

     □ X-rays during pregnancy: _______________________________________

     □ Medications used during pregnancy: _______________________________

     □ Alcohol used during pregnancy: (Frequency) ________________________

     □ Tobacco used during pregnancy: (Frequency) ________________________

     □ Other drugs used during pregnancy:

                   Type                      Frequency               Prescription

          _________________     _______________   Yes   No

          _________________     _______________   Yes   No

          _________________     _______________   Yes   No

 

 

Birth

At this child’s birth, what was the mother’s age? _______          Father’s? ______

Mother’s age at birth of first child? ________

Was this child born in a hospital?    Yes     No      If no, where? ______________

          Length of pregnancy: ________weeks       Birth weight: _____lbs_____oz

          Length of labor: ________hours               Apgar score _______________

          Child’s condition at birth _______________________________________

          Mother’s condition at birth ______________________________________

Check any of the following complications that occurred during birth.

          □ Forceps used         □ Breech birth          □ Labor induced        □ C-section

          □ Other delivery complications: __________________________________

          □ Jaundiced: Bilirubin lights? …….. No   Yes      If yes, how long? _________

          □ Breathing problems right after birth? ____________________________

                   Supplemental oxygen? …… No    Yes     If yes, how long? _________

Was anesthesia used during delivery? …………… No           Yes   

                   If yes, what kind? _______________________________________

Length of stay in hospital: Mother_______________days Child:_______days

 

Development

At what age did this child first do the following?    Please indicate year/month  of age

          ____________ Turn over               ____________ Walk down stairs

          ____________ Sit alone                ____________ Show interest to sound

          ____________ Crawl                     ____________ Understand first words

          ____________ Stand alone            ____________ Speak first words

          ____________ Walk alone              ____________ Speak in sentences

          ____________ Walk up stairs

 

Was this child breast-fed?    ……… No     Yes        When weaned? ____________

Was this child bottle-fed?    ……… No     Yes        When weaned? ____________

Was was this child toilet trained?    Days:__________       Nights:____________

Did bed-wetting occur after toilet training? …. No    Yes   Until what age?_______

Did bed-soiling occur after toilet training? …… No    Yes   Until what age?_______

Were there any medical reasons for bed-wetting or –soiling?                No      Yes

                   If yes, please describe: ___________________________________

Has this child experienced any of the following problems?  If yes, please describe.

          Walking difficulty …………. No          Yes____________________________

          Unclear speech …………….. No         Yes____________________________

          Feeding problem ………….. No Yes____________________________

          Underweight problem …… No Yes____________________________

          Overweight problem …….. No Yes____________________________

          Colic ………………………………. No         Yes____________________________

          Sleep problem ………………. No Yes____________________________

          Eating disorder ……………… No          Yes____________________________

          Learning to ride a bike …. No Yes____________________________

          Learning to skip ……………. No          Yes____________________________

          Throwing/catching ……….. No         Yes____________________________

During the child’s first 4 years, were any special problems noted in the following areas?  If yes, please describe.

          Eating ………………………….. No          Yes____________________________

          Motor skills ………………….. No           Yes____________________________

          Sleeping too much ………. No           Yes____________________________

          Temper tantrums …………  No Yes____________________________

          Sleeping too little ………… No           Yes____________________________

          Failure to thrive ……………. No          Yes____________________________

          Separation/parents ………. No          Yes____________________________

          Excessive crying …………… No          Yes____________________________

Which hand does the child use for writing or drawing? _____________________

          Eating? ________________            Other? _________________________

Has the child ever been forced to change writing hand?             No      Yes

 

Medical History

Please check the illnesses this child has had and indicate age (year/month).

          □ Measles ___________                □ Rheumatic fever ___________

          □ German measles ___________      □ Diphtheria ____________

          □ Mumps ___________                  □ Meningitis ____________

          □ Chicken pox _____________        □ Encephalitis ___________

          □ Tuberculosis _____________       □ Anemia ___________

          □ Whooping cough  ___________    □ Fever above 104° __________

          □ Scarlet fever __________________________________________

          □ Head injury: Describe ___________________________________

          □ Coma/loss of consciousness ______________________________

          □ Sustained high fever ____________________________________

Please describe other serious illnesses or operations:

                             Illness/Operation                                   Age

          _____________________________________               ________

          _____________________________________               ________

          _____________________________________               ________

Has this child ever been on long-term medication?          No      Yes

          If yes, when? ______________       What kind? ________________

 

Please indicate whether this child currently has any of the following problems.  If yes, describe how often.

Respiratory

          Frequent colds ……….. No              Yes ________________________

          Chronic cough ………… No               Yes ________________________

          Asthma …………………… No               Yes ________________________

          Hay fever ……………….. No               Yes ________________________

          Sinus condition ………. No               Yes ________________________

Cardiovascular

          Shortness of breath … No              Yes ________________________

          Activity limitation due to heart condition

                                        No              Yes _________________________

          Heart murmer …………. No               Yes _________________________

Gastrointestinal

          Excessive vomiting …. No               Yes _________________________

          Frequent diarrhea …… No               Yes _________________________

          Constipation ……………. No              Yes _________________________

          Stomach pain ………….. No              Yes _________________________

Genitourinary

          Urination in pants ….… No              Yes _________________________

          Pain while urinating …. No              Yes _________________________

          Excessive urination ….. No             Yes _________________________

          Strong odor to urine … No              Yes _________________________

Musculoskeletal

          Muscle pain ………………. No             Yes _________________________

                                                When? _________     Where? __________

          Clumsy walk …………….. No              Yes _________________________

          Poor posture …………….. No             Yes _________________________

          Other problems ………… No              If yes, describe ________________

          __________________________________________________________

Skin

          Frequent rashes ……….. No             Yes _________________________

          Bruises easily ……………. No             Yes _________________________

          Sores …………………………. No            If yes, describe ________________

          _________________________________________________________

          Severe acne ……….……… No            Yes __________________________

          Itchy skin …………………… No            Yes __________________________

 

Neurological

          Seizures/convulsions ….. No           If yes, describe _________________

          __________________________________________________________

          Speech defects …………… No           Yes __________________________

          Accident prone …………... No           Yes __________________________

          Bites nails …………………... No           Yes __________________________

          Sucks thumb ………………. No           Yes __________________________

          Grinds teeth ……………….. No           Yes __________________________

          Has tics/twitches ……….. No           Yes __________________________

          Bangs head …………………. No           Yes __________________________

          Rocks back/forth ………… No           Yes __________________________

          Bowel movements in pants or bed

                                           No           Yes __________________________

          Has this child ever taken medication to increase activity?

                                           No           If yes, when? __________________

                                                          What medication? _______________

          Has this child ever taken tranquilizing medication?

                                           No           If yes, when? __________________

                                                          What medication? _______________

Allergies

          Allergy to medicine ……. No            Yes __________________________

          _________________________________________________________

          Allergy to food …………… No            Yes __________________________

          _________________________________________________________

          Other allergies …………… No             Yes __________________________

          _________________________________________________________

 

Hearing

          Ear infections ……………. No             Yes __________________________

          Hearing problems ……… No              Yes __________________________

          Ear tubes ………………….. No             Yes __________________________

          Date of more recent hearing exam _________________

 

Vision

          Vision problems ………… No              Yes __________________________

          Glasses/contacts ………. No            Yes __________________________

          Date of most recent vision exam __________________

 

Medical Care

          Child’s physician ____________________________________________

          Address ___________________________________________________

          How often does this child see a doctor ___________________________

                                                          Date of last visit ________________         Is this child currently on medication?    No                If yes, indicate type and reason ________________________________           __________________________________________________________   Has this child ever had psychological counseling or therapy          No      Yes     Counselor’s name ___________________________________________       

          Address _________________________________________________      Telephone _______________________________________________ 

          Type of counseling _________________________________________          ________________________________________________________          ________________________________________________________

          When? __________________________________________________

          Has this child ever had a neurological exam          No      Yes     Neurologist’s name ________________________________________   Address _________________________________________________        Telephone _______________________________________________  Reason for exam __________________________________________          ________________________________________________________

          Has this child ever had a psychological or psychiatric exam?   No    Yes Doctor’s name ____________________________________________      Address _________________________________________________        Telephone _______________________________________________  Reason for exam __________________________________________          ________________________________________________________

 

 

Family Health

Have any family members had any of the following?  If yes, please specify family member’s relationship to this child.  If child is not living with biological parents, please include health information on biological parents if known.

□ Cancer _____________________  □ Tay-Sachs disease _______________

□ Cystic fibrosis ________________ □ Diabetes _______________________

□ Heart disease ________________ □ Birth defect _____________________

□ Cerebral palsy ________________          □ High blood pressure ______________

□ Drug abuse __________________ □ Tourette’s syndrome ______________

□ Kidney disease ________________         □ Behavior disorder _________________

□ Migraine headaches ____________         □ Emotional disturbance _____________

□ Multiple sclerosis ______________         □ Mental illness ____________________

□ Physical handicap _____________          □ Mental retardation ________________

□ Stroke ______________________ □ Nervousness _____________________

□ Tuberculosis __________________         □ Seizures ________________________

□ Alzheimer’s _________________   _        □ Reading problem __________________

□ Hemophilia ___________________          □ Learning disability _________________

□ Huntington’s chorea ____________        □ Language problem _________________

□ Muscular dystrophy _____________       □ Food allergies ____________________

□ Parkinson’s disease _____________        □ Head injury ______________________

□ Sickle-cell anemia _____________          □ Other:  Describe _________________

__________________________________________________________________

Describe father’s present health ________________________________________

__________________________________________________________________

Describe mother’s present health _______________________________________

__________________________________________________________________

Has anyone in the family ever been in special education?           No      Yes

          If yes, describe ________________________________________________

__________________________________________________________________

 

Friendships

Please indicate how this child relates to other children

Has problems relating or playing with other children                   No      Yes

          If yes, describe ________________________________________________

__________________________________________________________________

Fights frequently with playmates …………….. No     Yes _______________________

Prefers playing with younger children ………. No     Yes _______________________

Prefers to play alone …………………………………. No     Yes _______________________

Are there children in the neighborhood?       No    Yes _______________________

What role does this child take in peer group games (i.e. leader, aggressor, etc.)?

          ____________________________________________________________

 

Recreation/Interests

What activities does this child enjoy?

          Sports: ______________________________________________________

__________________________________________________________________

          Hobbies: _____________________________________________________

__________________________________________________________________

          Other: _______________________________________________________

__________________________________________________________________

Has this child’s interest in participating in these activities declined recently?

          No      Yes (describe) ___________________________________________

 

Behavior/Temperament

Please indicate whether this child exhibits any of the following behaviors

Is easily overstimulated in play ……………………………………………………………. No        Yes

Seems overly energetic in play …………………………………………………………….. No       Yes

Has a short attention span ……………………………………………………………………. No      Yes

Seems impulsive ……………………………………………………………………………………. No       Yes

Lacks self-control …………………………………………………………………………………… No      Yes

Overreacts when faced with a problem ………………………………………………… No       Yes

Seems unhappy most of the time …………………………………………………………. No       Yes

Seems uncomfortable meeting new people ………………………………………….. No       Yes

Withholds affection …………………………………………………………………………………. No     Yes

Requires a lot of  parental attention ……………………………………………………… No      Yes

Hides feelings …………….... No          Yes              Has fears ….…….……… No     Yes

          If yes, describe ______________________________________________

________________________________________________________________

What makes this child angry? ________________________________________

________________________________________________________________

 


Adaptive Skills

Please indicate whether this child has the following skills

Dresses self ……………………………………………………………………………………………. No      Yes

Bathes self ……………………………………………………………………………………………… No      Yes

Buys gifts for others …………………………………………………………………….....…… No       Yes

Helps with household chores ………………………………………………………..…….… No       Yes

Knows how to find home or seek help if lost …………………………………….…. No       Yes

Has good table manners ……………………………………………………………………….. No       Yes

Says “please” and “thank you” ……………………………………………………………… No       Yes

Is able to tell time accurately ……………………………………………………………….. No      Yes

Does this child receive an allowance? …………………………………………………… No       Yes

          If yes, how does he/she spend it? ________________________________

_________________________________________________________________

 

Educational History

Preschool

Did/does this child attend preschool?         No      Yes (at what age?) __________

          Amount of time per day ___________        Days per week _____________

          Any problems in preschool?            No      Yes (describe) _____________

_________________________________________________________________

Did/does this child attend kindergarten?     No      Yes

          Any problems in kindergarten?        No      Yes (describe) _____________

_________________________________________________________________

 

Elementary/High School

Please indicate whether this child has had any of the following school experiences

          Has changed schools for reasons other than normal academic progression

No      Yes (when/why?) _______________________________________

          Has been retained a grade in school

No      Yes (when/why?) _______________________________________

          Has skipped a grade in school

No      Yes (when/why?) _______________________________________

          Has difficulty with reading

No      Yes (when/why?) _______________________________________

          Has difficulty with math

No      Yes (when/why?) _______________________________________

          Gets poor grades

No      Yes (when/why?) _______________________________________

          Has been tested for special education

No      Yes (when/why?) _______________________________________

          Currently is placed in special education class

No      Yes (hrs per day?) ______________________________________

          Dislikes going to school

No      Yes (when/why?) _______________________________________

          Is absent from school frequently

No      Yes (when/why?) _______________________________________

          Any concerns about the quality of the child’s school/teachers?  

No      Yes (describe) _________________________________________

 

 

If in high school, when will this child graduate? _____________________

 

 

Additional Comments

 

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________________
Helpful Forms

Click here to view and print forms for your appointment.

CLICK HERE