Autism Assessment Clinic

Developmental History Form

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Developmental History Form

Name
Name
Name
Surname
Sex:

Developmental History Form

Is English the client's primary speaking language:

Reason for Evaluation

Please list the reason(s) the client is being referred for the evaluation:

Family Information

Parents are:
As a child client lived/lives with as:

Sibling Information 1

Name of Sibling
Name of Sibling
Name
Surname
Sex:
Different Father?
Different Mother?
Lives with child?

Sibling Information 2

Name of Sibling
Name of Sibling
Name
Surname
Sex:
Different Father?
Different Mother?
Lives with child?

Sibling Information 3

Name of Sibling
Name of Sibling
Name
Surname
Sex:
Different Father?
Different Mother?
Lives with child?

Sibling Information 4

Name of Sibling
Name of Sibling
Name
Surname
Sex:
Different Father?
Different Mother?
Lives with child?

Sibling Information 5

Name of Sibling
Name of Sibling
Name
Surname
Sex:
Different Father?
Different Mother?
Lives with child?

How well does your child get along with his/her siblings?

Family History

Condition/Disorder
Addiction
Anxiety/Depression
ADHD/ADD
Autism Spectrum Disorder
Mental Health Diagnosis
Epilepsy/Seizure Disorder
Genetic Condition
Learning Difficulty
Speech/Language Needs

Pregnancy and Birth History

Was this pregnancy full term?
If not, how many days before / after expected due date was baby born?
Was this pregnancy assisted (IVF, surrogacy, donors)?
Was this a multiple birth?
if yes:
If yes were the babies identical?

Mother's Health During Pregnancy

Did the mother consume more than 2 glasses of alcohol a day during this pregnancy?
Did the mother smoke during pregnancy?
Did the mother consume illegal substances during the pregnancy?

Labour and Delivery

Please note whether any problems occurred during labour or delivery (tick all that apply):
Baby was born:

Newborn Period

Did the baby require any special care immediately after birth?
If yes, tick all that apply:
Did mother experience post natal depression?
Did parents bond with the baby?

Developmental History

Did they use a dummy or have any attachments (e.g. blankets, teddies, people)?
Have there been any difficulties with sleep (getting over to sleep, staying asleep, transitioning to own room etc)?

Social Development

As an infant/toddler, did the client:
Enjoy cuddling?
Enjoy social / people games?
Share enjoyment / interest?
Tend to be fussy/irritable?
Make appropriate eye contact?
Respond to his/her name?

In the first four years of life, were any differences noted in the following areas? If yes, please describe:

Temper Tantrums / Meltdowns
Separating from parents
Playing with other children

Speech and Language Development

Known to Speech and Language Therapy?

Did the following milestones develop on time? Please specify age (year/month).

Show interest in sound (by 3 months)
Babbling (by 4 to 6 months)
Understanding words (by 6-11 months)
Speaking first words (by 12 months)
Speaking in short phrases (by 24 months)

Motor Development

Known to Occupational Therapy or Physiotherapy?
Did they ever walk on their tip-toes?

Did the following milestones develop on time? Please specify age (year/month).

Turn over (by 6 months)
Sit alone (by 9-12 months)
Crawl (by 9-12months)
Stand alone (by 9-12 months)
Walk alone (by 12-18 months)
Managing stairs
Ball skills
Riding a bike
Which hand does the client prefer to use?
Can they hold a pen / pencil appropriately
Is writing legible (if age appropriate)

Diet

How was the client fed as an infant?
Does the client currently eat a varied diet?

Daily Living

What age was the client toilet trained?
Did bed-wetting/soiling occur after toilet training?
Is the client independent with toileting?
Willing to use public bathrooms?
Is the client independent for feeding?
Is the client independent for dressing?
Is the client independent for washing?

Do you recall a Significant LOSS of skills (not just a delay)? For example, a child who was speaking and then stopped.

Age of loss:
Age of loss:
Age of loss:

Educational History

Is/was the client on a formal education plan in school?
If yes:
What best describes the client’s current educational experience?

Medical History

Please tick any of the Diagnosis/Illnesses that apply, also indicate if this was in the past or current and at what age this applies.

Serious head injury
Other serious injury
Loss of consciousness
Sleep Difficulties
Birth abnormality
Seizures (any type)
Other Neurological Problem
Vision problems at birth
Requires glasses/contacts
Other vision problem
Hearing problems at birth
Deafness
Chronic ear infections
Vents inserted
Other Hearing problem
Oddly shaped/missing teeth
Extractions/cavities
Dental braces
Other Dental problem
Eczema
Ash leaf patches
Café-au-lait spots
Other Skin Problem
Failure to gain weight
Obesity
Short stature
Tall stature
Other Growth problem
Heart abnormalities at birth
Heart surgery
Heart rhythm abnormalities
High blood pressure
Other heart problem
Asthma
Pneumonia
Apnea or irregular breathing
Other Lung/breathing Problem
Swallowing problems
Gastroesophageal reflux
Chronic abdominal pain
Chronic diarrhea
Chronic constipation
Swallowing problems
Other Stomach/bowel Problem
Kidney/bladder abnormalities at birth
Kidney/bladder infections
Hyper/hypo mobility
Other Kidney/bladder problem
Scoliosis or spinal curvature
Anemia
Sickle cell disease
Chronic low platelet count
Bleeding /bruising problem
Other circulatory problem
Diabetes
Early puberty
Late or incomplete puberty
Other hormone problem
ADHD
Oppositional defiant
Anxiety disorder
Obsessive-compulsive
Depression
Bipolar disorder
Schizophrenia
Tic disorder (e.g., Tourette)
Learning difficulties
Eating disorder
Are immunisations up to date?
Specialised neurological and genetic tests

If yes:

Hospitalisations and surgeries

If yes:

Allergies (to medications, foods, environmental antigens, etc.)

If yes:

Has the client ever been known to Social Services?
Has there ever been any Child Protection Issues?
Has the client experienced trauma that may have impacted on development?

Medications

Improved?
Improved?
Improved?
Improved?
Improved?
SERVICES - Please indicate resources/services being received now or in the past:

Social Interaction

Peer Relationships - Please tick all that apply and provide relevant details:
What role does the client take in peer groups?