2740 South Jones Blvd, Las Vegas, NV 89146 Phone (702) 248-8866 • (800) 441-4483 Fax (702) 248-1339 • www.hbinetwork.com

DEVELOPMENTAL & PSYCHOSOCIAL HISTORY CHILD & ADOLESCENT

Today’s Date:

Child’s Name:

Date of Birth:

Gender: Male Female

School:

Age/Grade:

Classroom Type: Regular Other

Your Name:

Relation to the Child: Names of Household Members Living with the Child

Age

Relation to the Child

Names of Other Immediate Family Members NOT Living with the Child

Age

Relation to the Child

What are your main concerns about your child at this time?

Please indicate if the patient has a family history of any of the following conditions. (Check all that apply) Mother’s Side Father’s Side Mother’s Side  Seizure disorder  Hyperactivity        Early speech and language problems  Motor or vocal tics     Early reading or spelling problems  Restlessness or fidgeting     Early math problems  Attention or concentration problems     Drug or alcohol abuse  Anxieties, fears, or phobias     Depression or mania  Motor incoordination     Mental Retardation  Significant shyness     Psychosis or schizophrenia  Serious medical illness     Psychiatric hospitalization  Sexual abuse

Father’s Side         

PRENATAL (PREGNANCY) HISTORY Please mark any/all of the following regarding the mother’s condition/habits while pregnant with the child (patient). Check all that apply.

 Smoked cigarettes

 Daily  2 or more a week  Once in a while

 Drank alcohol

 Glass of Wine  Beer  Mixed drinks

 Used drugs

 Daily  2 or more a week  Once in a while

 Had bleeding

During what stage of the pregnancy: __________________________________________________________

Ave. number of cigarettes/day: ____________________

Ave. amount/times a week: _____________________________ Type of drugs: _________________________________

 Was prescribed medications What medication and why: __________________________________________________________________ Check if the mother experienced any of the following medical conditions during pregnancy:

 Loss of consciousness  Toxemia

 High blood pressure  Low blood pressure

 Gestational diabetes  Nutritional deficiency

 Emotional problems  Other (specify):

CHILD-ADOLESCENT DEVELOPMENTAL AND PSYCHOSOCIAL HISTORY • Page 1 of 5

NEONATAL (BIRTH) HISTORY Mother’s age at child’s birth:____________ Was pregnancy carried to full term? Yes No Labor was easy average difficult Baby’s birth weight:________lbs._____oz.

Were forceps used? Yes No

Did baby have breathing problems at birth? Yes No

Birth was head first breech Caesarian

Was baby in any kind of distress at birth? Yes No

Explain:

Check if the baby had any of following conditions at birth (check all that apply):

 Hydrocephalus  Brain tumor(s)  Brain infections  Turner’s Syndrome

 Convulsions  Hyper/hypoglycemia  Hyper/hypothyroidism 

 Blood disorder  High/low sodium  High/low calcium 

 Respiratory problems  Jaundice mild severe  Spinal Bifida 

EARLY CHILDHOOD (0 – 3 YEARS OLD) Check if you experience any of the following while the patient was a baby/toddler (check all the apply) Baby was generally  calm  cranky  happy  anxious  easy  difficult  active  overactive  underactive

 Colicky. Colic went away at _____ months.  Allergies to:________________________________________________________________  Had trouble sleeping  Problems ingesting food  Frequent ear infections  Fevers over 104 degrees  Loss of consciousness  Seizures  Meningitis or encephalitis  Vision problems (age 18+ months)  Clumsiness (*age 18+ months)  Speech disturbance (age 18+ months)  Aggressive behaviors (age 18+ months)  Difficulty understanding spoken words*  Hearing problems (age 18+ months)  Specific significant trauma (age 18+ months)  Significant odd behavior that worried you*  Baby was hospitalized. At what age/s and why? ________________________________________________________________________ Age when baby first sat up alone:_____________________________ Age when baby first walked: __________________________________ Age when baby uttered first word/s:___________________________ Age when baby uttered first phrase/s:___________________________ Age when child was successfully toilet-trained:__________________ Was toilet-training  easy  hard Did child lose bladder control repeatedly (following toilet training during the day? Did child lose bladder control repeatedly (following toilet training during the night? Did child lose bowel control (following toilet training during the day?

Yes No Yes No Yes No

If your child attended daycare, what did the caregivers tell you about your child? PRESCHOOL (AGE 3-5 YEARS OLD) HISTORY List any serious illness and/or hospitalization your child experienced during these 3 years. What illness

Hospitalized

How long

Outcome

Yes No Yes No Yes No Was your child?  Clumsy  Uncoordinated

 Anxious/Unhappy  Inattentive

 Non-compliant  Hard to discipline

Did your child attend  Preschool?  Kindergarten?

 Overly aggressive  Too energetic/restless

 Inarticulate  Unable to understand language

Did your child have significant separation anxiety at  Preschool?  Kindergarten?

During preschool/kinder, did your child have any of the following learning and related issues? Check all that apply.  Attention-span  Sitting still  Learning the ABC’s  Speech disturbance  Listening  Learning to count During preschool/kinder, did your child have any of the following problems getting along with other kids? Check all that apply.  Overly-aggressive  Not sharing  Withdrawn  Overly-shy At home during this age, what problems did you have when parenting your child? Check all that apply.  Didn’t listen  Clingy  Fighting with siblings  Trouble separating  Disobedient  Cried a lot  Not sharing  Worried about something bad happening to parents Were there significant marital problems during this stage? Yes No If your child was exposed to these problems (fighting, yelling, verbal/physical violence), how did your child react? ________________________ Did your child develop any of the following motor tics (sudden, brief, recurrent, meaningless movements)? Check all that apply.  Eye blinking  Shoulder shrugging  Abdominal tensing  Head jerking  Mouth movement  Arms jerking  Facial gestures  Finger movement  Imitating someone else’s moves  Other (specify) Did they last for more than 1 year? Yes No

List those that still exist: CHILD-ADOLESCENT DEVELOPMENTAL AND PSYCHOSOCIAL HISTORY • Page 2 of 5

Did your child develop any of the following vocal tics (sudden, brief, recurrent, meaningless movements)? Check all that apply.  Throat clearing  Snorting  Grunting  Imitating someone else’s words/sounds  Barking  Sniffling  Repeating own words  Repeating socially unacceptable or obscene words Did they last for more than 1 year? Yes No

List those that still exist: ELEMENTARY SCHOOL YEARS

Mark any of the following conditions, difficulties or experiences of your child during elementary school years. Check all that apply.

 Clumsiness  Attention span  Trouble telling left from right  Poor handwriting  Did not get along with peers

 Difficulties with Reading in the following:  Accuracy  Speed  Comprehension  Phonics (sound of language)

 Difficulties with Math in the following:  Basic addition  Basic subtraction  Multiplication tables  Concept of borrowing/remainders  Poor handwriting interferes with

 Entered into Special Reading Classes:  Reading Improvement Program (RIP)

 Difficulties with Spelling:  Writing letters backward  Need lots of help learning weekly spelling words

 Sloppy handwriting may be reason for poor spelling

lining up columns of numbers  Makes careless errors when left alone to do math homework

 Written composition with lots of spelling errors

 Learning correct spelling but forgetting

Grade Level:____________  Title I Reading Class Grade Level:____________  Special Education Resource Placement Grade Level:____________

the same words a week or so later

 Difficulties with Speech:  Understanding other’s speech  Trouble with own speech articulation  Held back in grade level(s):_____________  Received speech therapy

Mark any of the following characteristics you know about your child during ages 5-12 years old. Check all that apply:

 Make careless mistakes in schoolwork or other activities  Has trouble concentrating  Has problems listening  Has difficulty following instructions  Has problem organizing tasks and activities  Avoids/dislikes engaging in tasks that require mental effort  Often lose things (i.e., school assignments, pencils, books, or other materials) necessary for tasks and activities

 Easily distracted  Often forgetful in daily activities

 Become fidgety, squirmy, restless  Has trouble remaining seated in class  Often run around or climb in appropriate places  Has difficulty playing or occupying self quietly  Constantly “on the go”  Excessively talkative  Has trouble waiting turn in groups  Often interrupt or intrude on others  Often blurt out answers before the questions were asked

Have you, your spouse, your child’s teacher(s), or someone else ever use the word “hyperactive” to describe your child? Yes No Who used the term? Yes No

Was your child ever prescribed medication for attention/hyperactive disturbance? If yes, what medication? At what age?

Was it effective? Yes No

For how long?

Unsure

Mark any of the following behaviors you know about your child during ages 5-12 years old. Check all that apply:

 Fears separation from home or parents  Fears that harm may happen on either parents  Fears going to school  Has excessive fear of being left alone  Reluctant to go to sleep at night

 Worries that unwarranted events will lead to separation  Afraid to be away from home overnight  Has repeated nightmares with the theme of separation from parents  Complains of physical pain (i.e., stomachaches, headaches) when

separating from parents In the past 12 months, has your child behaved in the following ways? (Check all that apply)  Often threatened or intimidated others  Forced someone into sexual activity  Often been truant from school, beginning before age 13 years  Often initiated physical fights  Broken into someone else’s property  Was there any behavior listed on left  Used a weapon in a fight  Often lied to obtain goods, or “cons” others that began prior to 10 years old  Been physically cruel to animals  Stolen valuable items without confronting  Juvenile Court involvement victim (e.g., shoplifting, forgery)  Been physically cruel to people What charges? _______________________  Often stayed out at night despite parental  Stolen while confronting a victim prohibition ____________________________________  Set fires on property  Ran away from home overnight How serious do you consider these charges? more than once  Deliberately destroyed other’s property Mild Moderate Severe During the past 6 months, has your child behaved in the following manner? (Check all that apply)

 Repeatedly lost his/her temper  Often argued with adults  Often defied adult requests or rules

 Deliberately annoyed other people  Often blamed others for own mistakes  Been easily annoyed by others

 Been angry and resentful  Been spiteful or vindictive

CHILD-ADOLESCENT DEVELOPMENTAL AND PSYCHOSOCIAL HISTORY • Page 3 of 5

Over the last 6 months, has your child shown the following symptoms/behaviors? (Check all that apply)

 restless or felt keyed up or on edge

 irritable

 easily fatigued

 muscle tension

 difficulty concentrating or mind

 sleep disturbance (difficulty falling asleep,

going blank

 overly worried about their performance at school or in sporting events

restless / unsatisfying sleep)

 overly worried about the future  worried about things done in the past that may not be acceptable to others

 overly conforming, perfectionistic and unsure of self and requires excessive reassurance about his/her performance Over the past year, have you notice any of the following about your child? (Check all that apply)

   

Had excessive fear of weight gain Has excessive fear of weight loss Felt fat when he/she is not Refused to maintain a minimally normal weight for his/her age and height

   

Dieted excessively Used laxatives, diuretics or speed Self-induced vomiting after meals In a menstruating female, missed at least three consecutive periods

 Engaged in binge eating  Fasted or exercised excessively  Overly evaluated him/herself according to his/her body weight

Recently, has your child used/abused any of the following: • Alcohol

Yes No Occasionally Frequently

• Amphetamines, speed or diet pills

Yes No Occasionally Frequently

• Marijuana

Yes No Occasionally Frequently

• Any form of Cocaine

Yes No Occasionally Frequently

• Sedatives, hypnotics and anxiolytics (Valium, sleeping pills, etc.)

Yes No Occasionally Frequently

• Hallucinogens

Yes No Occasionally Frequently

• Inhalants

Yes No Occasionally Frequently

• Opiates (heroin, morphine, codeine, etc.)

Yes No Occasionally Frequently

• Phencyclidine (PCP, hog, tranquilizer, angel dust, etc.)

Yes No Occasionally Frequently Yes No Occasionally Frequently

Does your child smoke or chew tobacco? Over the past year, has your child exhibited any of the following: • significant irritability, depressed or sad mood lasting several days

Yes No Mild Moderate Severe

• loss of interest or pleasure in activities that he/she usually enjoys

Yes No Mild Moderate Severe

• complained of appetite changes or sudden weight gain or loss

Yes No Mild Moderate Severe

• frequent problems with insomnia or hypersomnia (problems falling asleep or oversleeping)

Yes No Mild Moderate Severe

• significantly restless or noticeably lethargic

Yes No Mild Moderate Severe

• fatigued, tired or listless nearly every day

Yes No Mild Moderate Severe

• felt worthless or excessively guilty (low self-worth)

Yes No Mild Moderate Severe

• difficulty concentrating in school or at home

Yes No Mild Moderate Severe

• preoccupied with thoughts of death, suicide or has attempted suicide

Yes No Mild Moderate Severe

• had periods of enormous energy with little need to sleep

Yes No Mild Moderate Severe

• more talkative than usual

Yes No Mild Moderate Severe

• become excessively involved in pleasurable activities with negative consequences (buying sprees, sexual indiscretion, etc.)

Yes No Mild Moderate Severe

Over the past year, has your child felt any of the following: • been bothered by recurrent or persistent disturbing thoughts

Yes No

• attempted unsuccessfully to ignore recurrent or persistent disturbing thoughts

Yes No

• overly concerned with washing and cleaning, counting, checking, repeating actions and ordering

Yes No

In the past year, has your child complained of any of the following: • frequent headaches

Yes No Mild Moderate Severe

• frequent backaches

Yes No Mild Moderate Severe

• frequent muscle aches, soreness, tension

Yes No Mild Moderate Severe

• frequent stomach problems (nausea, diarrhea, bloating, etc.)

Yes No Mild Moderate Severe

• problems with balance or coordination

Yes No Mild Moderate Severe

• shortness of breath

Yes No Mild Moderate Severe

• dizziness or light-headedness

Yes No Mild Moderate Severe

• trouble with vision (double vision, blindness, etc.)

Yes No Mild Moderate Severe CHILD-ADOLESCENT DEVELOPMENTAL AND PSYCHOSOCIAL HISTORY • Page 4 of 5

To your knowledge, has your child been sexually victimized (fondled, sexually abused, or raped)? If yes, what age(s):

By whom:

Was your child ever been physically or emotionally abused?

Yes No

If yes, what age(s):

By whom:

Yes No

Has your child exhibited any of the following (while not on drugs)? (Check all that apply)

 Heard voices talking to him/her

 Experienced visual hallucinations  Had bizarre or very unusual thoughts When disciplining your child, do both parents discipline the same way? Yes No Are you consistent in enforcing consequences? Yes No If you answer “no” to one of these questions, please describe the methods of discipline you have tried and how they affect you and your child.

Describe how your child gets along with peers:  has many friends  wants to run things  is very popular

 shy  has trouble time making friends  follows what others say  afraid that others don’t like him/her

 poor loser at games  does not compromise easily  picks on other children  gets picked on or bullied by others

Describe Mother-Child relationship. How do they get along?

Describe Father-Child relationship. How do they get along?

Describe Step/Adopted Parent-Child relationship (if applicable). How do they get along?

List any medical or psychiatric conditions your child has been diagnosed with:

List any allergies your child has: List all medication(s) your child has been prescribed or presently taking for the current condition(s): Medication Dose & Frequency

Prescribing MD

List all treatments/services your child has received for his/her condition(s): Type of Treatment

Provider/Clinician’s Name

Frequency

Date of Last Visit

 Primary Care MD  Individual Counseling  Family/Group Counseling  Medication Management  Psychosocial Rehab  In your own opinion, describe your child’s attributes, strengths and personality traits. Write any other information you would like to share with your therapist about your child not mentioned above.

Parent/Guardian’s Signature:

Date: CHILD-ADOLESCENT DEVELOPMENTAL AND PSYCHOSOCIAL HISTORY • Page 5 of 5