CHILD HISTORY

OPT Form 92 V1 (1-2) JAN 07

Clinical Unit:

Form Date: - -Month Day Year

attach PID label here

Patient ID: - -

DCC USE

Received:

Date

Seq. No.:Form

Coordinator Code:

OBSTETRICS & PERIO THERAPY STUDY II

3. What is your relationship to the child?

Biological mother1

Stepmother2

Adoptive mother3

Foster mother/father4

Grandmother/grandfather5

Biological father6

Stepfather7

Adoptive father8

Other relative9

4. Who is the primary caregiver of the child?

Biological mother1

Stepmother2

Adoptive mother3

Foster mother/father4

Grandmother/grandfather5

Biological father6

Stepfather7

Adoptive father8

Other relative9

6. Are there other people who take care of the child who do not live with the child? (Example: answer NO if an aunt lives with the parent and child and watches the child.)

Yes1

No26a. Relationship to child: ____________________________________________

6b. Hours per week they take care of the child:

21Visit:

1. What is the child's date of birth? - -Month Day Year

2. What is the child's gender? Male1 Female2

5. Does the child live with the biological parent(s)?

One1 Two2Yes1 5a. Number of biological parents living with the child:

No2monthsYes1

No2

5b. Did the child ever live with the biological parent(s)?

5c. For how long:

OPT Form 92 V1 (2-2) JAN 07

OBSTETRICS & PERIO THERAPY STUDY II Patient ID: - -

13. Does the child sleep through the night? Yes1 No2 Don't know3

13a. At what age did he/she start to sleep through the night? months

Placid, happy1 Irritable and difficult to console3

Irritable, but easily consoled2

12. How best would you describe the infant's state from birth to 3 months?

Don't know4

14. At what age did the child first roll over? months Don't know1

15. At what age did the child first sit up? months Don't know1

16. At what age did the child first crawl? months Don't know1

17. At what age did the child first pull to a stand? months Don't know1

18. At what age did the child first walk? months Don't know1

8. Is this Visit 1? Yes1 No2 STOP

10. Was your child cuddly as an infant? Yes1 No2 Don't know3

11. Was your child colicky as an infant? Yes1 No2 Don't know3

11a. At what age was the colic outgrown? months

9. Has the child ever been breastfed? [Breastfeeding includes any suckling from the breast or feeding the child breastmilk for any duration, even once]

Yes1

Don't know3

No29a. At what age (in months) did the child stop breastfeeding? months

[ If less than one month, fill in 00][If can't remember at all, leave blank]

7. Has the child ever received or is currently receiving therapy?

Yes1

No2

What kind?

Yes1 No27a. Occupational therapy

Yes1 No27b. Physical therapy

Yes1 No27c. Speech therapy

Yes1 No27d. Educational therapy

9b. [If still breast feeding at present time, fill in present age of child in months months

- OR -