Autism Assessment Clinic
Autism Assessment Clinic
Developmental History Form
Developmental History Form
Date Form Completed:
Person Completing the Form:
Name
Name
Name
Name
Surname
Surname
Date of Birth
Sex:
Male
Female
Client’s Preferred Pronouns:
Developmental History Form
Is English the client’s primary speaking language:
Yes
No
If no, what is the client’s primary language:
Reason for Evaluation
Please list the reason(s) the client is being referred for the evaluation:
1.
2.
3.
When did these concerns arise?
What are your goals for this evaluation?
Family Information
Mother/Guardian Name:
Father/Guardian Name:
Parents are:
Married
Unmarried, Living Together
Never Married, Living Together
Separated
Divorced
Mother Deceased
Father Deceased
As a child client lived/lives with as:
Biological Mother
Biological Father
Step-parent
Adoptive Parent (specify)Adoptive Parent (specify)
Grandparent
Legal Guardian (specify)Legal Guardian (specify)
Other (specify)Other (specify)
Sibling Information 1
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
Sibling Information 2
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
Sibling Information 3
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
Sibling Information 4
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
Sibling Information 5
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
How well does your child get along with his/her siblings?
Very Well
Good
Average
Fair
Poor
Family History
Condition/Disorder
Addiction
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Anxiety/Depression
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
ADHD/ADD
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Autism Spectrum Disorder
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Mental Health Diagnosis
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Epilepsy/Seizure Disorder
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Genetic Condition
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Learning Difficulty
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Speech/Language Needs
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Pregnancy and Birth History
Was this pregnancy full term?
Yes
No
If not, how many days before / after expected due date was baby born?
Before
After
Number of Days
Was this pregnancy assisted (IVF, surrogacy, donors)?
Yes
No
Unknown
If yes, please specify:
Was this a multiple birth?
Yes
No
Unknown
if yes:
Twins
Triplets
Quadruplets
If yes were the babies identical?
Yes
No
Unknown
Mother’s Health During Pregnancy
No health problems during pregnancy
Poor weight gain
Seizures
High blood pressure
Health during pregnancy not known
Severe nausea (with dehydration)
Infections (Flu, measles, CMV)
Eclampsia/Toxemia
Rh (blood group) incompatibility
Other (specify)Other (specify)
List any medications taken during this pregnancy:
Did the mother consume more than 2 glasses of alcohol a day during this pregnancy?
Yes
No
Did the mother smoke during pregnancy?
Yes
No
Did the mother consume illegal substances during the pregnancy?
Yes
No
Labour and Delivery
No problems during labour and delivery
Not known
Please note whether any problems occurred during labour or delivery (tick all that apply):
Excessive bleeding
Meconium staining
Fever or infection of mother
Placenta previa or abruption
Forceps Used
Umbilical cord around baby’s neck
Breathing difficulties of child
Placenta broke more than 1 day before delivery
Other (specify):Other (specify):
Baby was born:
Head first
Breech (feet first)
Vaginal
Cesarean (reason?)Cesarean (reason?)
Birth weight:
Birth weight:
Apgar Scores (if known):
Apgar Scores (if known):
Newborn Period
Did the baby require any special care immediately after birth?
Yes
No
If yes, tick all that apply:
In Neo-Natal or SCBU for #days (specify)In Neo-Natal or SCBU for #days (specify)
Breathing problems (requiring oxygen ventilator (with a tube in windpipe))
Placement in an incubator
Blood transfusions
Significant muscle weakness or paralysis
Poor muscle tone
Seizures
Feeding difficulties
Jaundice treated with lights
Infection
Surgery (describe):Surgery (describe):
Did mother experience post natal depression?
Yes
No
Did parents bond with the baby?
Yes
No
How would you describe their temperament in the early weeks and months (e.g. settled, unsettled, passive, demanding etc)?
Developmental History
Did they use a dummy or have any attachments (e.g. blankets, teddies, people)?
Yes
No
If yes, please specify:
Have there been any difficulties with sleep (getting over to sleep, staying asleep, transitioning to own room etc)?
Previously Yes
Previously No
Currently Yes
Currently No
If yes, please specify:
Social Development
As an infant/toddler, did the client:
Enjoy cuddling?
Yes
No
if no, please give details
Enjoy social / people games?
Yes
No
if no, please give details
Share enjoyment / interest?
Yes
No
if no, please give details
Tend to be fussy/irritable?
Yes
No
if no, please give details
Make appropriate eye contact?
Yes
No
if no, please give details
Respond to his/her name?
Yes
No
if no, please give details
In the first four years of life, were any differences noted in the following areas? If yes, please describe:
Temper Tantrums / Meltdowns
YesYes
No
Separating from parents
YesYes
No
Playing with other children
YesYes
No
Speech and Language Development
Known to Speech and Language Therapy?
Yes
No
If yes, please specify:
Did the following milestones develop on time? Please specify age (year/month).
Show interest in sound (by 3 months)
YesYes
NoNo
Babbling (by 4 to 6 months)
YesYes
NoNo
Understanding words (by 6-11 months)
YesYes
NoNo
Speaking first words (by 12 months)
YesYes
NoNo
Speaking in short phrases (by 24 months)
YesYes
NoNo
Motor Development
Known to Occupational Therapy or Physiotherapy?
Yes
No
If yes, please specify:
Did they ever walk on their tip-toes?
Yes
No
If yes, at what age did this stop?
Did the following milestones develop on time? Please specify age (year/month).
Turn over (by 6 months)
YesYes
NoNo
Sit alone (by 9-12 months)
YesYes
NoNo
Crawl (by 9-12months)
YesYes
NoNo
Stand alone (by 9-12 months)
YesYes
NoNo
Walk alone (by 12-18 months)
YesYes
NoNo
Managing stairs
YesYes
NoNo
Ball skills
YesYes
NoNo
Riding a bike
YesYes
NoNo
Which hand does the client prefer to use?
Right
Left
Both
Can they hold a pen / pencil appropriately
Yes
No
Is writing legible (if age appropriate)
Yes
NoNo
Diet
How was the client fed as an infant?
Breast
Bottle
Combination
Describe how the weaning period went
Does the client currently eat a varied diet?
Yes
No
Please describe:
Daily Living
What age was the client toilet trained?
DaysDays
NightsNights
Did bed-wetting/soiling occur after toilet training?
Yes
No
If yes, until what age?
Is the client independent with toileting?
Yes
NoNo
Willing to use public bathrooms?
Yes
NoNo
Is the client independent for feeding?
Yes
NoNo
Is the client independent for dressing?
Yes
NoNo
Is the client independent for washing?
Yes
NoNo
Do you recall a Significant LOSS of skills (not just a delay)? For example, a child who was speaking and then stopped.
Social functioning:
Age of loss:
Explain:
Speech / language:
Age of loss:
Explain:
Bladder/bowel control:
Age of loss:
Explain:
Educational History
Most recent school:
Highest level of education reached:
Is/was the client on a formal education plan in school?
Yes
No
If yes:
Learning plan
Statement of Special Educational Needs
What best describes the client’s current educational experience?
Full time in a mainstream school
Time split between regular and special education classes
Full time in a special education class / unit
Teaching assistant or extra help
Specialized school
Home education
Emotional / anxiety-based school absence
Please describe the client’s school experience (did they enjoy school, any school-based anxiety, bullying, concerns raised by school, friendships etc):
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
Past
Current
AgeAge
Other serious injury
Past
Current
AgeAge
Loss of consciousness
Past
Current
AgeAge
Sleep Difficulties
Past
Current
AgeAge
Birth abnormality
Past
Current
AgeAge
Seizures (any type)
Past
Current
AgeAge
Other Neurological Problem
Past
Current
AgeAge
Vision problems at birth
Past
Current
AgeAge
Requires glasses/contacts
Past
Current
AgeAge
Other vision problem
Past
Current
AgeAge
Hearing problems at birth
Past
Current
AgeAge
Deafness
Past
Current
AgeAge
Chronic ear infections
Past
Current
AgeAge
Vents inserted
Past
Current
AgeAge
Other Hearing problem
Past
Current
AgeAge
Oddly shaped/missing teeth
Past
Current
AgeAge
Extractions/cavities
Past
Current
AgeAge
Dental braces
Past
Current
AgeAge
Other Dental problem
Past
Current
AgeAge
Eczema
Past
Current
AgeAge
Ash leaf patches
Past
Current
AgeAge
Café-au-lait spots
Past
Current
AgeAge
Other Skin Problem
Past
Current
AgeAge
Failure to gain weight
Past
Current
AgeAge
Obesity
Past
Current
AgeAge
Short stature
Past
Current
AgeAge
Tall stature
Past
Current
AgeAge
Other Growth problem
Past
Current
AgeAge
Heart abnormalities at birth
Past
Current
AgeAge
Heart surgery
Past
Current
AgeAge
Heart rhythm abnormalities
Past
Current
AgeAge
High blood pressure
Past
Current
AgeAge
Other heart problem
Past
Current
AgeAge
Asthma
Past
Current
AgeAge
Pneumonia
Past
Current
AgeAge
Apnea or irregular breathing
Past
Current
AgeAge
Other Lung/breathing Problem
Past
Current
AgeAge
Swallowing problems
Past
Current
AgeAge
Gastroesophageal reflux
Past
Current
AgeAge
Chronic abdominal pain
Past
Current
AgeAge
Chronic diarrhea
Past
Current
AgeAge
Chronic constipation
Past
Current
AgeAge
Swallowing problems
Past
Current
AgeAge
Other Stomach/bowel Problem
Past
Current
AgeAge
Kidney/bladder abnormalities at birth
Past
Current
AgeAge
Kidney/bladder infections
Past
Current
AgeAge
Hyper/hypo mobility
Past
Current
AgeAge
Other Kidney/bladder problem
Past
Current
AgeAge
Scoliosis or spinal curvature
Past
Current
AgeAge
Anemia
Past
Current
AgeAge
Sickle cell disease
Past
Current
AgeAge
Chronic low platelet count
Past
Current
AgeAge
Bleeding /bruising problem
Past
Current
AgeAge
Other circulatory problem
Past
Current
AgeAge
Diabetes
Past
Current
AgeAge
Early puberty
Past
Current
AgeAge
Late or incomplete puberty
Past
Current
AgeAge
Other hormone problem
Past
Current
AgeAge
ADHD
Past
Current
AgeAge
Oppositional defiant
Past
Current
AgeAge
Anxiety disorder
Past
Current
AgeAge
Obsessive-compulsive
Past
Current
AgeAge
Depression
Past
Current
AgeAge
Bipolar disorder
Past
Current
AgeAge
Schizophrenia
Past
Current
AgeAge
Tic disorder (e.g., Tourette)
Past
Current
AgeAge
Learning difficulties
Past
Current
AgeAge
Eating disorder
Past
Current
AgeAge
Are immunisations up to date?
Yes
No
If no, specify:
Specialised neurological and genetic tests
Yes
No
If yes:
Test
Age
Result
Test
Age
Result
Test
Age
Result
Hospitalisations and surgeries
Yes
No
If yes:
Reason for hospitalisation/surgery
Age
Length of stay
Reason for hospitalisation/surgery
Age
Length of stay
Reason for hospitalisation/surgery
Age
Length of stay
Allergies (to medications, foods, environmental antigens, etc.)
Yes
No
If yes:
Source (medication, food, etc.)
Nature of reaction (hives, trouble breathing, etc.)
Source (medication, food, etc.)
Nature of reaction (hives, trouble breathing, etc.)
Source (medication, food, etc.)
Nature of reaction (hives, trouble breathing, etc.)
Source (medication, food, etc.)
Nature of reaction (hives, trouble breathing, etc.)
Has the client ever been known to Social Services?
Yes
No
If yes, specify:
Has there ever been any Child Protection Issues?
Yes
No
If yes, please specify:
Has the client experienced trauma that may have impacted on development?
Yes
No
If yes, please specify:
Medications
No medications taken now or ever
Medications taken now or previously (please specify):
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
SERVICES – Please indicate resources/services being received now or in the past:
No services
Early Intervention Services such as DIS / CDC / Paediatrics (Specify:)Early Intervention Services such as DIS / CDC / Paediatrics (Specify:)
Speech/Language therapy Physiotherapy Occupational therapy
Other:Other:
Social Interaction
Peer Relationships – Please tick all that apply and provide relevant details:
Has problems relating to peersHas problems relating to peers
Has difficulty making friendsHas difficulty making friends
Fights frequently with peersFights frequently with peers
Prefers interacting with younger peoplePrefers interacting with younger people
Prefers interacting with older peoplePrefers interacting with older people
Prefers to be alonePrefers to be alone
Has a best friendHas a best friend
Approaches unfamiliar peersApproaches unfamiliar peers
Prefers 1:1 / small group interactionsPrefers 1:1 / small group interactions
What role does the client take in peer groups?
Leader
Follower
Some of each
What are the client’s personal strengths?
Any other information that you think might be useful?
Submit
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Autism Assessment Clinic
Developmental History Form
Developmental History Form
Date Form Completed:
Person Completing the Form:
Name
Name
Name
Name
Surname
Surname
Date of Birth
Sex:
Male
Female
Client’s Preferred Pronouns:
Developmental History Form
Is English the client’s primary speaking language:
Yes
No
If no, what is the client’s primary language:
Reason for Evaluation
Please list the reason(s) the client is being referred for the evaluation:
1.
2.
3.
When did these concerns arise?
What are your goals for this evaluation?
Family Information
Mother/Guardian Name:
Father/Guardian Name:
Parents are:
Married
Unmarried, Living Together
Never Married, Living Together
Separated
Divorced
Mother Deceased
Father Deceased
As a child client lived/lives with as:
Biological Mother
Biological Father
Step-parent
Adoptive Parent (specify)Adoptive Parent (specify)
Grandparent
Legal Guardian (specify)Legal Guardian (specify)
Other (specify)Other (specify)
Sibling Information 1
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
Sibling Information 2
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
Sibling Information 3
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
Sibling Information 4
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
Sibling Information 5
Name of Sibling
Name of Sibling
Name
Name
Surname
Surname
Sex:
Male
Female
Age:
Different Father?
Yes
No
Different Mother?
Yes
No
List any health/behavior/learning needs
Lives with child?
Yes
No
How well does your child get along with his/her siblings?
Very Well
Good
Average
Fair
Poor
Family History
Condition/Disorder
Addiction
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Anxiety/Depression
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
ADHD/ADD
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Autism Spectrum Disorder
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Mental Health Diagnosis
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Epilepsy/Seizure Disorder
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Genetic Condition
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Learning Difficulty
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Speech/Language Needs
Mother
Father
Brother
Sister
Grandparent
Aunt/Uncle
Other Close Relatives
Pregnancy and Birth History
Was this pregnancy full term?
Yes
No
If not, how many days before / after expected due date was baby born?
Before
After
Number of Days
Was this pregnancy assisted (IVF, surrogacy, donors)?
Yes
No
Unknown
If yes, please specify:
Was this a multiple birth?
Yes
No
Unknown
if yes:
Twins
Triplets
Quadruplets
If yes were the babies identical?
Yes
No
Unknown
Mother’s Health During Pregnancy
No health problems during pregnancy
Poor weight gain
Seizures
High blood pressure
Health during pregnancy not known
Severe nausea (with dehydration)
Infections (Flu, measles, CMV)
Eclampsia/Toxemia
Rh (blood group) incompatibility
Other (specify)Other (specify)
List any medications taken during this pregnancy:
Did the mother consume more than 2 glasses of alcohol a day during this pregnancy?
Yes
No
Did the mother smoke during pregnancy?
Yes
No
Did the mother consume illegal substances during the pregnancy?
Yes
No
Labour and Delivery
No problems during labour and delivery
Not known
Please note whether any problems occurred during labour or delivery (tick all that apply):
Excessive bleeding
Meconium staining
Fever or infection of mother
Placenta previa or abruption
Forceps Used
Umbilical cord around baby’s neck
Breathing difficulties of child
Placenta broke more than 1 day before delivery
Other (specify):Other (specify):
Baby was born:
Head first
Breech (feet first)
Vaginal
Cesarean (reason?)Cesarean (reason?)
Birth weight:
Birth weight:
Apgar Scores (if known):
Apgar Scores (if known):
Newborn Period
Did the baby require any special care immediately after birth?
Yes
No
If yes, tick all that apply:
In Neo-Natal or SCBU for #days (specify)In Neo-Natal or SCBU for #days (specify)
Breathing problems (requiring oxygen ventilator (with a tube in windpipe))
Placement in an incubator
Blood transfusions
Significant muscle weakness or paralysis
Poor muscle tone
Seizures
Feeding difficulties
Jaundice treated with lights
Infection
Surgery (describe):Surgery (describe):
Did mother experience post natal depression?
Yes
No
Did parents bond with the baby?
Yes
No
How would you describe their temperament in the early weeks and months (e.g. settled, unsettled, passive, demanding etc)?
Developmental History
Did they use a dummy or have any attachments (e.g. blankets, teddies, people)?
Yes
No
If yes, please specify:
Have there been any difficulties with sleep (getting over to sleep, staying asleep, transitioning to own room etc)?
Previously Yes
Previously No
Currently Yes
Currently No
If yes, please specify:
Social Development
As an infant/toddler, did the client:
Enjoy cuddling?
Yes
No
if no, please give details
Enjoy social / people games?
Yes
No
if no, please give details
Share enjoyment / interest?
Yes
No
if no, please give details
Tend to be fussy/irritable?
Yes
No
if no, please give details
Make appropriate eye contact?
Yes
No
if no, please give details
Respond to his/her name?
Yes
No
if no, please give details
In the first four years of life, were any differences noted in the following areas? If yes, please describe:
Temper Tantrums / Meltdowns
YesYes
No
Separating from parents
YesYes
No
Playing with other children
YesYes
No
Speech and Language Development
Known to Speech and Language Therapy?
Yes
No
If yes, please specify:
Did the following milestones develop on time? Please specify age (year/month).
Show interest in sound (by 3 months)
YesYes
NoNo
Babbling (by 4 to 6 months)
YesYes
NoNo
Understanding words (by 6-11 months)
YesYes
NoNo
Speaking first words (by 12 months)
YesYes
NoNo
Speaking in short phrases (by 24 months)
YesYes
NoNo
Motor Development
Known to Occupational Therapy or Physiotherapy?
Yes
No
If yes, please specify:
Did they ever walk on their tip-toes?
Yes
No
If yes, at what age did this stop?
Did the following milestones develop on time? Please specify age (year/month).
Turn over (by 6 months)
YesYes
NoNo
Sit alone (by 9-12 months)
YesYes
NoNo
Crawl (by 9-12months)
YesYes
NoNo
Stand alone (by 9-12 months)
YesYes
NoNo
Walk alone (by 12-18 months)
YesYes
NoNo
Managing stairs
YesYes
NoNo
Ball skills
YesYes
NoNo
Riding a bike
YesYes
NoNo
Which hand does the client prefer to use?
Right
Left
Both
Can they hold a pen / pencil appropriately
Yes
No
Is writing legible (if age appropriate)
Yes
NoNo
Diet
How was the client fed as an infant?
Breast
Bottle
Combination
Describe how the weaning period went
Does the client currently eat a varied diet?
Yes
No
Please describe:
Daily Living
What age was the client toilet trained?
DaysDays
NightsNights
Did bed-wetting/soiling occur after toilet training?
Yes
No
If yes, until what age?
Is the client independent with toileting?
Yes
NoNo
Willing to use public bathrooms?
Yes
NoNo
Is the client independent for feeding?
Yes
NoNo
Is the client independent for dressing?
Yes
NoNo
Is the client independent for washing?
Yes
NoNo
Do you recall a Significant LOSS of skills (not just a delay)? For example, a child who was speaking and then stopped.
Social functioning:
Age of loss:
Explain:
Speech / language:
Age of loss:
Explain:
Bladder/bowel control:
Age of loss:
Explain:
Educational History
Most recent school:
Highest level of education reached:
Is/was the client on a formal education plan in school?
Yes
No
If yes:
Learning plan
Statement of Special Educational Needs
What best describes the client’s current educational experience?
Full time in a mainstream school
Time split between regular and special education classes
Full time in a special education class / unit
Teaching assistant or extra help
Specialized school
Home education
Emotional / anxiety-based school absence
Please describe the client’s school experience (did they enjoy school, any school-based anxiety, bullying, concerns raised by school, friendships etc):
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
Past
Current
AgeAge
Other serious injury
Past
Current
AgeAge
Loss of consciousness
Past
Current
AgeAge
Sleep Difficulties
Past
Current
AgeAge
Birth abnormality
Past
Current
AgeAge
Seizures (any type)
Past
Current
AgeAge
Other Neurological Problem
Past
Current
AgeAge
Vision problems at birth
Past
Current
AgeAge
Requires glasses/contacts
Past
Current
AgeAge
Other vision problem
Past
Current
AgeAge
Hearing problems at birth
Past
Current
AgeAge
Deafness
Past
Current
AgeAge
Chronic ear infections
Past
Current
AgeAge
Vents inserted
Past
Current
AgeAge
Other Hearing problem
Past
Current
AgeAge
Oddly shaped/missing teeth
Past
Current
AgeAge
Extractions/cavities
Past
Current
AgeAge
Dental braces
Past
Current
AgeAge
Other Dental problem
Past
Current
AgeAge
Eczema
Past
Current
AgeAge
Ash leaf patches
Past
Current
AgeAge
Café-au-lait spots
Past
Current
AgeAge
Other Skin Problem
Past
Current
AgeAge
Failure to gain weight
Past
Current
AgeAge
Obesity
Past
Current
AgeAge
Short stature
Past
Current
AgeAge
Tall stature
Past
Current
AgeAge
Other Growth problem
Past
Current
AgeAge
Heart abnormalities at birth
Past
Current
AgeAge
Heart surgery
Past
Current
AgeAge
Heart rhythm abnormalities
Past
Current
AgeAge
High blood pressure
Past
Current
AgeAge
Other heart problem
Past
Current
AgeAge
Asthma
Past
Current
AgeAge
Pneumonia
Past
Current
AgeAge
Apnea or irregular breathing
Past
Current
AgeAge
Other Lung/breathing Problem
Past
Current
AgeAge
Swallowing problems
Past
Current
AgeAge
Gastroesophageal reflux
Past
Current
AgeAge
Chronic abdominal pain
Past
Current
AgeAge
Chronic diarrhea
Past
Current
AgeAge
Chronic constipation
Past
Current
AgeAge
Swallowing problems
Past
Current
AgeAge
Other Stomach/bowel Problem
Past
Current
AgeAge
Kidney/bladder abnormalities at birth
Past
Current
AgeAge
Kidney/bladder infections
Past
Current
AgeAge
Hyper/hypo mobility
Past
Current
AgeAge
Other Kidney/bladder problem
Past
Current
AgeAge
Scoliosis or spinal curvature
Past
Current
AgeAge
Anemia
Past
Current
AgeAge
Sickle cell disease
Past
Current
AgeAge
Chronic low platelet count
Past
Current
AgeAge
Bleeding /bruising problem
Past
Current
AgeAge
Other circulatory problem
Past
Current
AgeAge
Diabetes
Past
Current
AgeAge
Early puberty
Past
Current
AgeAge
Late or incomplete puberty
Past
Current
AgeAge
Other hormone problem
Past
Current
AgeAge
ADHD
Past
Current
AgeAge
Oppositional defiant
Past
Current
AgeAge
Anxiety disorder
Past
Current
AgeAge
Obsessive-compulsive
Past
Current
AgeAge
Depression
Past
Current
AgeAge
Bipolar disorder
Past
Current
AgeAge
Schizophrenia
Past
Current
AgeAge
Tic disorder (e.g., Tourette)
Past
Current
AgeAge
Learning difficulties
Past
Current
AgeAge
Eating disorder
Past
Current
AgeAge
Are immunisations up to date?
Yes
No
If no, specify:
Specialised neurological and genetic tests
Yes
No
If yes:
Test
Age
Result
Test
Age
Result
Test
Age
Result
Hospitalisations and surgeries
Yes
No
If yes:
Reason for hospitalisation/surgery
Age
Length of stay
Reason for hospitalisation/surgery
Age
Length of stay
Reason for hospitalisation/surgery
Age
Length of stay
Allergies (to medications, foods, environmental antigens, etc.)
Yes
No
If yes:
Source (medication, food, etc.)
Nature of reaction (hives, trouble breathing, etc.)
Source (medication, food, etc.)
Nature of reaction (hives, trouble breathing, etc.)
Source (medication, food, etc.)
Nature of reaction (hives, trouble breathing, etc.)
Source (medication, food, etc.)
Nature of reaction (hives, trouble breathing, etc.)
Has the client ever been known to Social Services?
Yes
No
If yes, specify:
Has there ever been any Child Protection Issues?
Yes
No
If yes, please specify:
Has the client experienced trauma that may have impacted on development?
Yes
No
If yes, please specify:
Medications
No medications taken now or ever
Medications taken now or previously (please specify):
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
Medication
Dosage
Age at Start
Reason for medication
Improved?
Yes
No
SERVICES – Please indicate resources/services being received now or in the past:
No services
Early Intervention Services such as DIS / CDC / Paediatrics (Specify:)Early Intervention Services such as DIS / CDC / Paediatrics (Specify:)
Speech/Language therapy Physiotherapy Occupational therapy
Other:Other:
Social Interaction
Peer Relationships – Please tick all that apply and provide relevant details:
Has problems relating to peersHas problems relating to peers
Has difficulty making friendsHas difficulty making friends
Fights frequently with peersFights frequently with peers
Prefers interacting with younger peoplePrefers interacting with younger people
Prefers interacting with older peoplePrefers interacting with older people
Prefers to be alonePrefers to be alone
Has a best friendHas a best friend
Approaches unfamiliar peersApproaches unfamiliar peers
Prefers 1:1 / small group interactionsPrefers 1:1 / small group interactions
What role does the client take in peer groups?
Leader
Follower
Some of each
What are the client’s personal strengths?
Any other information that you think might be useful?
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