Child History Form

The information requested in this form is treated as CONFIDENTIAL. The questions are designed to help me understand your
concerns about your child. If you have any questions about the requested information, please do not hesitate to ask.

Name: ________________________________________________________________Birth date:______________ Age: _____

Home Address:_____________________________________________________

____________________________________________________ Zip Code: _____________________________

Grade: _______School:____________________________________ School Address: __________________________________

Parent/Guardian’s Phone: Home: ( ) ______________________ Work: ( )__________________________

Parent’/Guardian’s Work Hours: ____________________________________________________________________________

Father’s Name:__________________________________________________________________________________________

Age: _______ Education: ________________________________ Occupation: _________________________________

Mother’s Name:_________________________________________________________________________________________

Age: _______ Education: ________________________________ Occupation: _________________________________

Are the above named the child’s: Biologic Parent(s) Adoptive Parent(s) Stepparent(s)

OTHER GENERAL FAMILY INFORMATION

Is the child adopted? No Yes

If Yes, at what age was he/she adopted? ________________________________

If Yes, does he/she know of the adoption? ________________________________

• Please list all persons living in the home with the child/adolescent whom we will be evaluating.

Names of Current Residents Age Relationship to Child Educational Attainment

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Are the child’s parents separated or divorced? £ No £ Yes

If Yes, answer the following questions.
• When did separation occur (month/year)?__________________________________________________
• When was the divorce final (month/year)?__________________________________________________
• Who has legal custody? ________________________________________________________________
• Who has physical custody? _____________________________________________________________

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Other General Family Information (continued)

• Does the noncustodial parent: £ Have Regular/Frequent Contact with Son/Daughter

£ Know of this Evaluation
£ Insure the Child
£ Have Limited/Unpredictable Contact

• If the child does not live with biologic or adoptive parent(s), please provide the following information regarding
guardianship.
Are you:
£ A Foster Parent(s)

£ A legal guardian(s) who is a biologic relative: State relationship ______________________________

£ A legal guardian(s) who is not a biologic relative

Foster Parent/Guardian’s Name: ____________________________________________________

Address: Phone: (____)_________________
_________________________________________ Zip Code: ____________

• Please state why child is in foster care or with a guardian.____________________________________

___________________________________________________________________________________________

Please state the problem(s) your child is experiencing which led you to seek help.
_____________________________________________________________________________________________
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Did anyone suggest/require you to seek help for your child?
£ NO £ YES
If yes, who and for what reason(s) if different from the above reason?
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

GENERAL BEHAVIOR

• Please check any items below which describe your child’s typical behavior. That is, how he/she is MOST of the time.
£ Sociable £ Prefers Company £ Cooperative £ Respectful £ Optimistic
£ Unsociable £ Prefers to be Alone £ Stubborn £ Defiant £ Pessimistic

£ Easygoing, Calm £ Good eye contact £ Confident £ Takes Risks £ Others

£ Irritable £ Poor eye contact £ Expects Failure £ Cautious
£ Active/Restless £ Caring £ Sharing £ Generally Happy
£ Overly dependent £ Uncaring £ Selfish £ Generally Unhappy

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PROBLEM BEHAVIORS

• Please check any of the behaviors which occur excessively or frequently NOW AND/OR IN THE PAST.
£ Worries £ Skipping Classes/School £ Reckless/Careless Behavior £ Mood Swings
£ Fears £ Legal Problems £ Disruptive Behavior £ Sadness
£ Obsessive Thoughts £ Runs Away from Home £ Messy £ Depression
£Compulsive/Repetitive Behavior £ Tantrums, Angry Outbursts £ Accident Prone £ Crying Spells
£ Odd Thoughts £ Bullies £ Short Attention Span £ Irritable
£ Odd Behavior £ Argues £ Distractible £ Withdrawn
£ Disturbing Thoughts £ Defiant/Op positional £ Impulsive £ Boredom
£ Nightmares £ Fights £ Hyperactive £ Significant Appetite
£ Night terrors £ Lies £ Learning Problems
£ Insomnia £ Steals £ Speech Problems
£ Sleepwalking £ Destroys property £ Poor School Work
£ Will Not Sleep Alone £ Sets Fires
£ Missing School Due to Illness £ Cruelty to Animals
£ Frequent Physical Complaints £ Sexual Activity

For Clinician’s Use.________________________________________________________________________

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________________________________________________________________________________________

• Has your child ever talked about or attempted suicide? £ No £ Yes

If Yes, when and what were the circumstances?
___________________________________________________________________________________________

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• Has your child ever talked seriously about hurting or killing someone/something, or done so? £ No £ Yes
If Yes, when and what were the circumstances?
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To your knowledge has your child ever been physically abused? £ No £ Yes
If Yes, when and what were the circumstances?
_____________________________________________________________________________________________
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Has your child ever been the victim of sexual abuse? £ No £ Yes
If Yes, please explain.
_____________________________________________________________________________________________
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BIRTH TO FIVE YEARS DEVELOPMENTAL HISTORY

• Mother’s Pregnancy: £ Normal £ Complicated [Explain]_____________________________________________

_____________________________________________________________________________________________
• Check any substances the biologic mother used during her pregnancy and comment on any item checked.
£ Tobacco £ Alcohol £ Drugs £ Medications
_____________________________________________________________________________________________
_____________________________________________________________________________________________
• Check any of the following that pertain to the biologic mother’s delivery:
£ Full Term £ Vaginal Delivery £ Premature £ C-Section £ Fetal Distress
Please explain any complications.__________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

• Child’s condition at birth: £ Normal £ Abnormal

If Abnormal, please explain.______________________________________________________________________
• Birth Weight: ___________ lbs. ___________ oz.

• As an infant was your child:

£ Easy to Manage £ Irritable £ Demanding
£ Alert/Responsive £ A Poor Eater £ A Poor Sleeper
At what age did your child:
Sit up unassisted: ________ Walk without support: _______ Use first words: _______
Use sentences: ________ Toilet trained for daytime: _______ Dry at night: _______
• Was toilet training easy or difficult? £ Easy £ Difficult

Does your son/daughter: £ Bed wet £ Daytime wet £Soil and/or has bowel movements in underclothing. Please comment
on any checked item.____________________________________________________________
• By or before the time your child entered kindergarten did you, your child’s physician or any of your child’s preschool
teachers have concerns about any of the following areas of development?
£ Language Development [Use of words and sentences] £ Balance/Coordination £ Vision
£ Speech Development [Pronunciation] £ Behavior Problems £ Intelligence
£ Fine Motor Development [pencil grip, coloring, cutting, etc.] £ Hearing

SCHOOL HISTORY

Current School: Phone: (_______)__________________________

Address: ________________________________________

• Has your child repeated a grade? £ No £ Yes

If Yes, which grade(s)? ______________________________________________

• Has your child been assessed for special education services? £ No £ Yes
If Yes, when? ______________________________________________________
Is your child/adolescent receiving Special Education services now? £ No £ Yes
If Yes, what type? ___________________________________________________
Was your child/adolescent in Special Education in past years? £ No £ Yes
If Yes, when and what type of special education was he/she certified to receive?
__________________________________________________________________

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SCHOOL HISTORY (continued)

• Please write in the school or district (i.e., city, township, different state) attended by your child for each grade, and the
usual marks attained. Check any of the problems listed for each of the grades in which they occurred. Please list any
repeated grades on the blank lines below.

Grade Name of School Academic Learning Peer Short Hyper- Behavior Expelled
Grades Probs. Probs. Attention activity Probs. Or
Span Suspended
K ____________ ______ £ £ £ £ £ £
1 ____________ ______ £ £ £ £ £ £
2 ____________ ______ £ £ £ £ £ £
3 ____________ ______ £ £ £ £ £ £
4 ____________ ______ £ £ £ £ £ £
5 ____________ ______ £ £ £ £ £ £
6 ____________ ______ £ £ £ £ £ £
7 ____________ ______ £ £ £ £ £ £
8 ____________ ______ £ £ £ £ £ £
9 ____________ ______ £ £ £ £ £ £
10 ____________ ______ £ £ £ £ £ £
11 ____________ ______ £ £ £ £ £ £
12 ____________ ______ £ £ £ £ £ £
____________ ______ £ £ £ £ £ £
____________ ______ £ £ £ £ £ £
____________ ______ £ £ £ £ £ £

FAMILY CULTURAL AND/OR ETHNIC INFORMATION

As a family, do you identify yourself with a particular cultural or ethnic group? £ No £ Yes
If Yes, please note cultural/ethnic identification and the influence or role it plays in family life.
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RELIGIOUS AND/OR SPIRITUAL INFORMATION

• Do you regularly attend church as a family? £ Yes £ No

• What is the Religious/Spiritual Orientation of your family? _________________________________________
• How does your religious/spiritual orientation affect family life? ______________________________________
__________________________________________________________________________________________

SOCIAL/RECREATIONAL/STUDY TIME INFORMATION

• How many hours per week does your son/daughter spend in social/leisure time activities? __________________
• Is your son/daughter involved in any organized sports or recreational activities? £ No £ Yes If Yes, please note what activities
and how many hours per week. _________________________________________________________________
• How many hours per week does your son/daughter study and/or do homework? __________________________

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SIGNIFICANT LIFE EVENTS

• Please check any of the following events which have occurred in your child’s life and his/her age when it occurred.
Event or Situation Age Event or Situation Age
£ Change of residence ______ £ Family gambling problems ______
£ Change of schools ______ £ Family psychiatric problems ______
£ Change of custody ______ £ Family chronic illness ______
£ Marital conflict ________ £ Other family problems ______
£ Parents separated ______ £ Rejection by family member(s) ______
£ Parents divorced ______ £ Abuse to self (verbal, physical, sexual) ______
£ Parent visitation problems ______ £ Witnessed abuse to others ______
£ Post divorce parent conflict ______ £ Victim of abuse ______
£ Parent(s) remarried ______ £ Suffered/Witnessed significant accident or injury ______
£ Step parent problems ______ £ Other severe fright or trauma ______
£ Sibling birth ______ £ Death of family member or friend ______
£ Acquired step sibling(s) ______ £ Suicide of family member or friend ______
£ Family economic problems ______ £ Death or pet ______
£ Family job problems ______ £ Other_____________________ ______
£ Family substance abuse ______

PREVIOUS INTERVENTION THERAPY HISTORY

• Has your child received any intervention therapy in the past? £ No £ Yes
If Yes, please indicate in the space provided below.

TYPE OF TREATMENT DATE (mm/dd/yyyy) TREATMENT FACILITY & THERAPIST

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 FAMILY PSYCHIATRIC & SUBSTANCE USE HISTORY

• Please check any family members with a history of difficulties in the areas noted.
RELATIONSHIP DEPRESSION MANIA ANXIETY PSYCHOSIS ADHD ASD ALCOHOL/DRUGS
Mother £ £ £ £ £ £ £
Father £ £ £ £ £ £ £
Siblings £ £ £ £ £ £ £
Other Relatives £ £ £ £ £ £ £

FAMILY MEDICAL HISTORY

• Please check any family members with a history of difficulties in the areas noted.
RELATIONSHIP CHRONIC NEUROLOGIC SEIZURE THYROID MENTAL
MEDICAL DISORDERS DISORDER DISORDER RETARDATION
PROBLEMS
Mother £ £ £ £ £
Father £ £ £ £ £
Siblings £ £ £ £ £
Other Relatives £ £ £ £ £

• Please make any additional comments you feel might be relevant regarding family members’ psychiatric, chemical
substance abuse, or medical history.

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MEDICAL HISTORY

• Are your child’s immunizations current? £ Yes £ No £ Unsure

• Date of most recent physical _______________ Results: £ Normal £ Other [Explain]

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MEDICAL HISTORY (continued)

• What is your son/daughter’s current: Height ___________ Weight ___________

• Please check any of the following medical or physical conditions that apply to your child.
£ Vision Problems £ Cardiac Problems £ Significant Weight Gain
£ Hearing Problems £ Diabetes £ Frequent Vomiting
£ Gross Motor Coordination Problems £ Sickle Cell Disease £ Frequent Headaches
£ Fine Motor Coordination Problems £ Genetic Disorder £ History of Migraines
£ Cerebral Palsy £ Asthma £ Frequent Stomach Aches
£ Seizure Disorder £ Allergies £ Frequently Ill
£ Loss of Menstruation (Amenorrhea) £ Chronic Ear Infections £ History of Febrile Seizures
£ Failure to thrive or growth retardation £ Tics (Twitches) £ History of Meningitis
£ History of Encephalitis £ Significant Weight Loss £ Other_______________

Is your child currently taking any medication(s)? £ No £ Yes

If Yes, please list name medications and daily
dosage.
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Has your child been hospitalized for medical treatment? £ No £ Yes

If Yes, when and for the treatment of what
condition?
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Please provide the following information about your child’s physician.

Name:
_____________________________________________________________________
Address:
___________________________________________________________________
City: ___________________________ State: ________ Zip Code:
_____________
Phone: (______)_____________________

Relationship of Adult Completing Form to the Child to be seen in Clinic:

£ Parent £ Foster Parent £ Guardian £ Other: _________________________________

___________________________________________ ___________________________________________
Signature of Adult Completing Form Date

____________________________________________ ___________________________________________
Signature of Clinician Reviewing Form Date

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