
The developmental history is an important part of your child’s speech, language and hearing evaluation. Please fill out
this form as completely and accurately as possible. Make a note of anything you have questions about and we can
discuss them during your appointment. 

Person completing this form (*) 
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Relationship to child (*) 
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Date (*) 
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I. IDENTIFICATION 

Name (*) 
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Birth date (*) 
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Phone (*) 
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Address (*) 
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Mother’s name (*) 
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Occupation (*) 
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Last grade completed in school (*) 
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Father’s name (*) 
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Occupation 
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Last grade completed in school (*) 
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Names of Brothers and Sisters 


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Age 


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Speech, Hearing or Medical Problems 


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II. AREAS OF CONCERN 

Please describe why you are having your child seen for a speechlanguage evaluation 
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How does the child usually communicate? (ie: gestures, single words, short phrases, sentences) 
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Please give two to three examples of the child’s comments that are typical at this time 
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When did you first become concerned? 
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Have there been any changes in the condition since you first noticed it? 
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Is the child aware of the problem? If so, how does he/she feel about it? 
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Have any other speechlanguage specialists seen the child? 
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If Yes, what were their conclusions or suggestions? 
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Have any other specialists seen the child? 
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If Yes, what type of specialists and what were their conclusions or suggestions? 
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Did seeing any of the above mentioned specialists help? 
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If Yes, please explain 
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Are there any incidences of any of the following conditions among the child’s family and close relatives? 

1. Speech Problems 
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Please Explain 
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2. Hearing Problems 
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Please Explain 
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3. Learning Disabilities 
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Please Explain 
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4. Seizures / Convulsions 
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Please Explain 
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5. Intellectual Disability 
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Please Explain 
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6. Autism / Spectrum Disorder 
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Please Explain 
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III. SPEECH, LANGUAGE AND HEARING HISTORY 

How much did the child babble and coo during the first 6 months? 
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What were the child’s first few words and at what age were they spoken? 
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How many words did the child have at 18 months? 
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When did the child begin to use twoword sentences? 
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Does the child make sounds incorrectly? 
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If Yes, which ones? 
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How well can the child be understood?(Poorly to Very Well) 

By his/her parents 
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Comments 
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By his/her siblings and playmates 
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Comments 
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By family friends and relatives 
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Comments 
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By strangers 
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Comments 
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Does the child hesitate, “get stuck”, repeat, or stutter on sounds or words? 
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If Yes, please describe 
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How does the child’s voice sound? 
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Did the development of the child’s speech ever slow down or did he/she ever stop talking? 
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If Yes, please explain 
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Does the child imitate words but not use them? 
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If Yes, please explain 
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Are there any other languages spoken in the home? 
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If Yes, which ones, by whom and how often? 
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How well does the child understand what is said to him/her? 
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How does the child’s speech compare to those of his/her siblings? 
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Does the child have ear infections? 
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If Yes, how often? 
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Does the child hear adequately? 
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If No, please describe 
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Does his/her hearing ability fluctuate? 
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If Yes, please explain 
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Has the child ever worn a hearing aid? 
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If Yes, in which ear, for how long have they worn it, and does it seem to help him/her? 
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Please check these as they apply to the child 

Cried less than normal amount 
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If Yes, please explain and give ages if possible 
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Laughed less than normal amount 
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If Yes, please explain and give ages if possible 
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Yelled or screeched to get attention or express annoyance 
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If Yes, please explain and give ages if possible 
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Head banging and foot stamping 
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If Yes, please explain and give ages if possible 
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Temper tantrums 
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If Yes, please explain and give ages if possible 
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Awkward or uncoordinated 
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If Yes, please explain and give ages if possible 
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Very alert to gestures, facial expression or movement 
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If Yes, please explain and give ages if possible 
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Very alert to gestures, facial expression or movement 
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If Yes, please explain and give ages if possible 
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Generally indifferent to sound 
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If Yes, please explain and give ages if possible 
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Did not respond when spoken to 
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If Yes, please explain and give ages if possible 
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Responded to noises (car horn, phone) but not to speech 
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If Yes, please explain and give ages if possible 
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Difficulty using tongue or ‘tongue tied’ 
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If Yes, please explain and give ages if possible 
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Large tongue 
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If Yes, please explain and give ages if possible 
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Difficulty Swallowing 
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If Yes, please explain and give ages if possible 
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Gags or chokes easily 
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If Yes, please explain and give ages if possible 
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Difficulty moving mouth 
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If Yes, please explain and give ages if possible 
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Drooled excessively 
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If Yes, please explain and give ages if possible 
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Food came out nose 
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If Yes, please explain and give ages if possible 
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Talked through nose 
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If Yes, please explain and give ages if possible 
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Excessive throat clearing 
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If Yes, please explain and give ages if possible 
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Mouth breathing 
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Difficulty breathing 
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If Yes, please explain and give ages if possible 
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IV. PREGNANCY AND BIRTH HISTORY 

Which pregnancy was this child 
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Length of pregnancy 
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Did any illness, disease and/or accidents occur during pregnancy? 
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If Yes, please explain 
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Did a blood incompatibility exist between the mother and father? 
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Age of mother at infant’s birth 
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Age of father at infant’s birth 
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Length of labor 
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Drugs used during labor 
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Were there any problems at birth, ie: breech, caesarean, fever, etc.? 
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If Yes, please explain 
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Were forceps used? 
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Weight of infant at birth 
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Child was 
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Were there any bruises or scars on the infant’s head? 
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Any other abnormalities of the infant’s head or body? 
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Did the infant require oxygen following birth? 
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Was the child “blue” or jaundiced at birth? 
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Was a blood transfusion required at birth? 
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Did the infant have a bowel movement before birth? 
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If you answered Yes to any of the questions above please explain 
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Were there any problems during the first two weeks of life, ie: health, swallowing, sucking, feeding, sleeping, etc.? If so, please explain: 
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V. MEDICAL HISTORY 

Is the child currently under the care of a doctor (aside from their primary care physician for general checkups)? 
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If Yes, please explain 
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Is he/she taking medication? 
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If Yes, what type and why? 
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Please indicate the age at which any of the following occurred and the severity 


Adenoidectomy 

Age 
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Allergies 

Age 
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Asthma 

Age 
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Blood disease 

Age 
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Cataracts 

Age 
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Chicken Pox 

Age 
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Chronic Colds 

Age 
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Convulsions 

Age 
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Crosseyed 

Age 
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Croup 

Age 
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Dental Problems 

medchild_denage 
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Diphtheria 

Age 
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Earaches 

Age 
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Headaches 

Age 
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Head Injury 

Age 
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Hearing Problems 

Age 
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High Fevers 

Age 
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Influenza 

Age 
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Mastoidectomy 

Age 
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Measles 

Age 
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Meningitis 

Age 
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Mumps 

Age 
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Muscle Disorder 

Age 
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Has the child ever fallen or had a blow to the head? 
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If Yes, did he/she lose consciousness? 
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VI. BEHAVIOR 

Did it cause a concussion? 
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Did it cause Nausea, Vomiting or Drowsiness? 
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Describe any other illness, injury, operation or physical problem not mentioned above 
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Did any of the above require hospitalization? 
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If Yes, please explain 
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Please indicate which of these apply to the child 

Eating problems 
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Explain and give ages if possible 
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Sleeping problems 
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Explain and give ages if possible 
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Toilet training problems 
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Explain and give ages if possible 
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Difficulty Concentrating 
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Explain and give ages if possible 
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Stays with an activity 
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Explain and give ages if possible 
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Needs a lot of discipline 
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Explain and give ages if possible 
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Underactive 
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Explain and give ages if possible 
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Overactive / Excitable 
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Explain and give ages if possible 
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Laughed Easily 
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Explain and give ages if possible 
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Cried a lot 
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Explain and give ages if possible 
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Sensitive 
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Explain and give ages if possible 
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Emotional 
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Explain and give ages if possible 
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Happy 
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Explain and give ages if possible 
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Irritable 
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Explain and give ages if possible 
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Personality Problem 
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Explain and give ages if possible 
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Gets along with children 
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Explain and give ages if possible 
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Gets along with adults 
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Explain and give ages if possible 
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Prefers to play alone 
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Explain and give ages if possible 
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Other 
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Explain and give ages if possible 
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Does the child separate from his/her parents without crying or fussing? 
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How do you discipline the child? 
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What are the child’s favorite play activities? 
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VII. DEVELOPMENTAL MILESTONES 


Please indicate the age at which the following occurred 

Rolled over alone 
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Sat upright alone 
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Crawled 
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Stood alone 
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Walked unaided 
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Fed self with spoon 
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Had first tooth 
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Dress/undress unaided 
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Bladder trained 
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Bowel trained 
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Toilet trained, waking 
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Toilet trained, sleeping 
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What hand does the child prefer? 
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Has handedness ever changed? 
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If Yes, at what age? 
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How would you describe the child’s current physical development? 
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VIII. EDUCATIONAL HISTORY 


List the schools attended/currently attending, please include nursery/preschools 

Name 
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Ages 
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Hours per week 
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Name 
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Ages 
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Hours per week 
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edu_current 
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Grades skipped 
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Grades skipped 
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Grades failed 
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Average grades 
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Best subjects 
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Is the child frequently absent from school? 
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If Yes, please explain why 
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How does the child feel about school and his/her teacher? 
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What is your impression of the child’s learning abilities? 
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Has anyone ever thought the child has learning problems? 
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If Yes please explain: 
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Describe any speech, language, hearing, psychological, and special education services that have been performed. Include where and how often 
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Thank you for taking the time to fill out this form, please add any additional information you feel will help us in understanding your child and his/her problem 
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Patient Name 
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