Childhood History Form

    Name of IFC Clinician:

    Child's Name:

    Grade:

    D.O.B.

    Source of Data:

    Child is presently living with: (to select multiple items, hold down Ctrl (Windows) or Command (Mac) and click with the left mouse button)

    Briefly state your view of the main problem/difficulty for your child:

    PARENTS:

    Parent 1:

    Relationship to child:

    Occupation:

    Business Phone:

    Age:

    Age at time patient was born:

    School:

    Highest Grade Completed:

    Learning Problems:

    Attention Problems:

    Behavioral Problems:

    Medical Problems:

    Have any of your blood relatives experienced problems similar to those your child is experiencing? If so, describe:

    Parent 2:

    Relationship to child:

    Occupation:

    Business Phone:

    Age:

    Age at time patient was born:

    School:

    Highest Grade Completed:

    Learning Problems:

    Attention Problems:

    Behavioral Problems:

    Medical Problems:

    Have any of your blood relatives experienced problems similar to those your child is experiencing? If so, describe:

    SIBLINGS:

    Name:

    Age:

    Medical, Social, or School Problems:

    PREGNANCY:

    Complications:

    Infections (specify):

    Operations (specify):

    Other illness(es) (specify):

    Smoking during pregnancy:

    Number of cigarettes per day:

    Alcohol consumption during pregnancy:

    Describe if beyond an occasional drink:

    Medications during pregnancy:

    X-ray studies during pregnancy:

    Duration of pregnancy:

    DELIVERY:

    Type of Labor:

    Duration (hrs):

    Type of Delivery:

    Complications:

    Birth Weight:

    POST DELIVERY PERIOD:

    Infections (specify):

    Number of days infant was in the hospital after delivery:

    INFANCY PERIOD:

    Were any of the following present – to a significant degree – during the first few years of life? If so, describe:

    Did not enjoy cuddling:

    Was not calmed by being held or stroked:

    Difficult to comfort:

    Colic:

    Excessive restlessness:

    Excessive irritability:

    Diminished sleep:

    Frequent head banging:

    Difficult nursing:

    Constantly into everything:

    MEDICAL HISTORY:

    If your child’s medical history includes any of the following, please note the age when the incident or illness occurred and any other pertinent information:

    Childhood diseases (describe ages and any complications):

    Operations:

    Hospitalization for illness:

    Head injuries:

    Convulsions:

    Coma:

    Persistent high fever:

    Eye problems:

    Ear problems:

    Allergies or Asthma:

    Poisoning:

    Sleep problems:

    Appetite:

    PRESENT MEDICAL STATUS:

    Approximate Height:

    Approximate Weight:

    Present illnesses for which the child is being treated:

    Medications child is taking on ongoing basis:

    DEVELOPMENTAL MILESTONES:

    If you can recall, record the age at which your child reached the following developmental milestones. If you cannot recall exactly, check the item below.

    Smiled:

    Sat without support:

    Crawled:

    Stood without support:

    Walked without assistance:

    Spoke first words:

    Said phrases:

    Said sentences:

    Bladder trained, day:

    Bladder trained, night:

    Bowel trained, day:

    Bowel trained, night:

    Rode tricycle:

    Rode bicycle (without training wheels):

    Buttoned clothing:

    Tied shoelaces:

    Named colors:

    Named coins:

    Said alphabet in order:

    Began to read:

    COORDINATION:

    Rate your child on the following skills:

    Walking:

    Running:

    Throwing:

    Catching:

    Shoelace tying:

    Buttoning:

    Writing:

    Athletic Abilities:

    Excessive number of accidents compared to other children:

    COMPREHENSION AND UNDERSTANDING:

    Do you consider your child able to understand directions and situations as well as other children his or her age? If not, why not?:

    How would you rate your child’s overall level of intelligence compared to other children:

    SCHOOL HISTORY:

    Were you concerned about your child’s ability to succeed in kindergarten? If so, please explain:

    Rate your child's school experiences related to academic learning:

    Nursery School:

    Kindergarten:

    Current Grade:

    To the best of your knowledge, at what grade level is your child functioning:

    Reading:

    Spelling:

    Arithmetic:

    Has your child ever had to repeat a grade? If so, when?

    Present class placement:

    Kinds of special counseling or remedial work your child is currently receiving:

    Describe briefly any academic school problems:

    Rate your child's school experiences related to behavior:

    Nursery School:

    Kindergarten:

    Current Grade:

    Does your child’s teacher describe any of the following as significant classroom problems?

    Describe briefly any other classroom behavioral problems:

    As best as you can recall, please use the following space to provide a general description of your child’s school progress in each grade.

    PEER RELATIONSHIPS:

    Does your child seek friendships with peers?

    Is your child sought by peers for friendship?

    Does your child play with children primarily his or her own age?

    Describe briefly any problems your child may have with peers:

    INTERESTS AND ACCOMPLISHMENTS:

    What are your child’s main hobbies and interests?

    What are your child’s areas of greatest accomplishment?

    What does your child enjoy doing most?

    What does your child dislike doing most?

    What do you like about your child?

    LIST NAMES AND ADDRESSES OF ANY OTHER PROFESSIONALS CONSULTED

    (including family doctor):

    1.

    2.

    3.

    4.

    ADDITIONAL REMARKS:

    Signature of Parent or Guardian

    Date