Ahwatukee Psychological Services

DEVELOPMENTAL HISTORY FORM

Name: ___________________________                            Today’s Date______________

Is this child            ___Adopted            ___ Foster       ___Biological   ___ Other

This form serves two purposes. The first is for us to obtain complete record of the requested information which will help us prepare for the child’s consultation. The second is to help you anticipate what areas of your child’s development you may want to stress during the consult as significant to his or her current functioning.

DEVELOPMENTAL HISTORY:

Developmental Milestones- Motor

 Was your child’s early gross motor abilities: __Normal   __Clumsy   __Robotic __Other

Was your child’s early fine motor abilities:    __Normal   __Adequate __Poor     __Other

Developmental Milestones- Speech, Language, Communication

Please rate the following areas as they best apply:

                                                                   _Normal       Adequate      Concern      Poor

Babbling at 6 months                                        1                      2               3                4

First word at 12 months                                  1                      2               3                4

  First word was

2 word combination at 24 mos.                      1                       2               3                4

3 word combination at 3 mos.                        1                       2               3                4

Speech Problems:

Misarticulating: __No               __Yes              __Describe_________________

Speech was                  __Normal         __Slow            __Rapid/pressured       Other ______

Inflection was:               __Normal         __Flat              __Mechanical               __Pedantic

Does (or did) your child’s quality of language or conversational content includes:

Cohesion in conversation                      ___Yes            __No

Idiosyncratic use of words                    ___Yes            __No

Respective patterns of speech               ___Yes            __No

Echolalia                                               ___Yes            __No

Conversation with others on

topics of mutual interest:                        ___Yes            __No

None- verbal / Non-literal Communication:

Please rate the following abilities as they best apply:

                                                                       Normal        Adequate       Concern       Poor

Interpreting facial expression:                1                      2                      3              4

Using facial expression:                                     1                      2                      3              4

Making eye-contact:                                         1                      2                      3              4

Giving messages with eyes:                                1                      2                      3              4

Using hand gestures:                                         1                      2                      3              4

Cognizant of body in space:                              1                      2                      3              4     

Maintains proper distance from others:  1                      2                      3              4 Maintains body posture:                             1                      2                      3              4

Responding to nonverbal cues in                      

Conversation:                                                   1                      2                      3              4

Do you suspect your child could read facial expressions and use body language if prompted, or do you feel he or she has a deficit in this ability? ___________________

_____________________________________________________________________

Does your child understand:

Non-literal speech:                    __Yes              __No  

Irony    Sarcasm:                      __Yes              __No

Joking:                                      __Yes              __No

Metaphors:                               __Yes              __No  

Intent of communication:           __Yes              __No

Emotions:  Please rate the following as they relate to emotions:

Understanding of emotions:       __Full range     __Only knows Sad, Happy, Angry       __Difficulty with understanding

Changes In affect:                     __ Smooth       __Fixed            __Abrupt         Other__

Did (or does) your child have difficulty understanding the feelings of others?  Yes   No

Cognitive Functioning:  Does (or is) your child:

Good at details:

See the whole picture:

Able to generate alternative solutions to problems:

Social Interactions:

Does your child feel anxious in situations involving new people?

Is your child preoccupied with inner world or “out of touch”?

Did (or does) your child engages in mutual sharing of interests?

Currently, is your child’s play?

__independent    __parallel (beside)     __interactive with peers   __cooperative

Social Functioning:

Check all that apply to your child BOTH PAST AND PRESENT

                                                                                                Yes                  No

Take care of personal needs:                                                     ___                  ___

Have close friends:                                                                    ___                  ___

Avoid others:                                                                            ___                  ___     

Have interest in friends:

Have the skills to interact with others:                            ___                  ___

Have the following rite of entry skills (or deficits)

            Greet other in an appropriate manner:                ___                  ___                 

            Read cues to enter group:                                             ___                  ___                 

            Difficulty or clumsy approach to group:              ___                  ___

Have exit skills:                                                             ___                  ___

Does your child

Usually share and take turns willingly?                           __yes               __no

Usually plays well with two or more children?                __yes               __no

Willingly and cooperatively participates in a

small group, activity or game?                                       __yes               __no

Have one sided response to conversations                                 __yes               __no

Have a one sided response to peers                                          __yes               __no

Interest:

Is your child’s range of interest?

____ Nonexistent (child doesn’t like anything)    

____ Restricted to 1 interest (child seems obsessed by one area of interest)

____ Restricted to 1 or 2 interests

____ Typical

____ Other

Please rate your child’s history with the following abilities, as they best apply

                                                Over-developed           Normal Under-developed

Savant skills:                                         1                           2                             3

Rote memory of facts:                           1                           2                             3

Please check all that describes your child’s current use of toys

___Sequenced, lined up            ___Repetitive                                                    ___Restrictive

___Cognitive flexibility  ___Able to shift from one theme to another

___Preoccupation with parts   ___Symbolic use

Comments:

Sensory integration

Did or does your child have sensory integration difficulties (difficulty with sensory system modulation)   __Yes __No    Explain:

Self-stimulation Behaviors

Does (or did) your child engages in self stimulating behaviors (e.g. flapping, rocking, sifting, etc.)?

Need for sameness:

Did or does your child have:

Difficulties in transition                                                               __Yes    __No

Difficulty with small, non functional changes in routines or details            __Yes    __No            

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