Child Developmental History Record

A. Identifications

1. Child’s name: _____________________________________________ Birthdate: ______________ Age: _________________

Person(s) completing this form: ____________________________________________ Today’s date: ________________________

2. Mother’s name: __________________________________ Birthdate: ____________ Home phone: ________________________

Address: _____________________________________________________________________________________________________

Currently employed: ❑ No ❑ Yes, as: ________________________________________ Work phone: _________________________

3. Father’s name: __________________________________ Birthdate: _____________Home phone: _______________________

Address: _____________________________________________________________________________________________________

Currently employed: ❑No ❑Yes, as: ____________________________________________ Work phone: _____________________

4. Parents are currently ❑ Married ❑ Divorced ❑ Remarried ❑ Never married ❑ Other: __________________________________

Child’s custodian/guardian is: ____________________________________________________________________________________

5. Stepparent’s name: _________________________________ Birthdate: ___________ Home phone:_____________________

Address: _____________________________________________________________________________________________________

Currently employed: ❑ No ❑ Yes, as: ___________________________________________ Work phone: _____________________

6. Other adult family members? ___________________________________________________________________________________

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B. Development

Please fill in any information you have on the areas listed below.

1. Pregnancy and delivery

Prenatal medical illnesses and health care: _________________________________________________________________________
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Was the child premature? ❑ No ❑ Yes. Weight and height at birth: _______________ pounds, ounces _________________ inches
Any birth complications or problems? ______________________________________________________________________________
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2. The first few months of life

Breast-fed? If so, for how long? Any allergies? _______________________________________________________________________
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Sleep patterns or problems: ______________________________________________________________________________________

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Personality: __________________________________________________________________________________________________
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3. Milestones: At what age did this child do each of these?

Sat without support: __________________ Crawled: ___________________ Walked without holding on: _____________________
Helped when being dressed: ___________ Tied shoelaces: ______________ Buttoned buttons: ____________________________
Ate with a fork: ______________________ Stayed dry all day: ____________ Didn’t soil his or her pants: _____________________
Stayed dry all night: __________________ Other: ______________________ Other: _____________________________________

4. Speech/language development

Age when child said first word understandable to a stranger: ____________________________________________________________

Age when child said first short sentence understandable to a stranger: ____________________________________________________
Any speech, hearing, or language difficulties? _______________________________________________________________________
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Other Communication Difficulty: __________________________________________________________________________________
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C. Health

List all childhood illnesses, hospitalizations, medications, allergies, head injuries, important accidents and injuries, surgeries, periods of
loss of consciousness, convulsions/seizures, and other medical conditions.

Condition Age Treated by whom? Consequences?

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D. Residences

1. Homes

Dates

From To Location With whom Reason for moving Any problems?

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2. Residential placements, institutional placements, or foster care

Dates

From To Program name/Location Reason for placement Problems?

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E. Schools

School (name, district, address, phone) Grade Age Teacher

Daycare: _____________________________________________________________________________________________________
Preschool: ___________________________________________________________________________________________________
Elementary School: ____________________________________________________________________________________________
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Middle School: ________________________________________________________________________________________________
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High School: _________________________________________________________________________________________________
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Secondary Education/Training: ___________________________________________________________________________________
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May I call and discuss your child with the current teacher? ❑ Yes ❑ No

F. Special skills or talents of child

List hobbies, sports; recreational, musical, TV, and toy preferences; etc.: __________________________________________________
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G. Other
Is there anything else I should know that doesn’t appear on this or other forms, but that is or might be important?
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