Name : _________________________________________________ Date: _______________________

Developmental History - At what age did your child first:

 Birth History:

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1. Any complications during this pregnancy? _____________________________________________

2. Any complications at birth? (Breech, Caesarean., Forceps): _______________________________

3.Full Term: _________________________  Premature: _____________________________________

4. Apgar Scores (if known): Birth ____________________    10 minutes ________________________

5. Has child had any serious accidents/injuries? ___________________________________________

6. Has child had any operations/serious illnesses? _________________________________________

7.  Does your child run high fevers? ____________________  Convulsions? _____________________

8. Does your child ever complain of headaches? ___________________________________________

9. Does your child have any unusual head or eye movement when working on small tasks? ________

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10. Is there any family history of mental retardation or learning problems: ________________________

11. Is your child easily frustrated? if yes, please explain. ______________________________________

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12. Please list any allergies your child has to food or medication. _______________________________