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Developmental-BehavioralPediatricsQuestionnaire(>5years):IDENTIFYINGINFORMATION:

NameofPersoncompletingquestionnaire:_________________________________________________Date:_______Email:__________________________RelationshiptoChild:______________________CONCERNS:Whatisyourmainquestion,reason,orhopeforthisvisit?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Whendidtheissuebegin?_______________________________________________________________Whathasalreadybeentried(orisnowbeingdone)toaddressit?_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Haschildpreviouslybeenevaluatedforthisissueorrelatedconcernsaboutdevelopment,behavior,oreducation? ☐Yes/☐NoWhodidtheevaluation?(Name) Date Whatdidtheytellyou?

EarlyStartorRegionalCenter

SchoolorIEPteam

Psychologistorpsychotherapist:

EducationSpecialist:

S&L,OT,PT:

Other:

Child’sName Child’sBirthdate/Gender SchoolName Teacher&Grade SchoolContact PrimaryDoctor ReferringDoctor BestLanguage forparent(s):☐English☐Spanish☐ Other: forchild:☐English☐Spanish☐ Other:

DEVELOPMENT & BEHAVIOR:

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Didthechildhaveanydelaysinearlydevelopment?☐Yes/☐NoIfso,describe:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Didyourchildeverloseskillshe/shepreviouslyhad?☐Yes/☐NoIfso,describe:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Ifyouremember,whendidyourchildbegindisplayingtheseskills?Skill Age Skill AgeSatwithouthelp Turnedtotheirownname Walkedwithoutholdingon Enjoyed"peek-a-boo" Ranwithoutfalling Saidfirstmeaningfulwords Usedforkorspoontofeedself Spoke2-wordphrases Catchabigball Spokeinfullsentences Drawacircle Followed1-stepcommands Dressself(exceptbuttons/zippers) Identifiedcolorsorbodyparts Toilettrainedindaytime Pretendorimaginaryplay Writefirstname Reciteletters/numbers 2-wheelbicycle Identifyletters/numbers Tieshoelaces Learningtoread

Howwouldyoudescribeyourchild’spersonality?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Whatdoeshe/sheliketodo?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Whatarehis/herstrengths&weaknesses?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Whennecessary,whatformofdisciplineworksbestwithyourchild?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DEVELOPMENT & BEHAVIOR:

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Howdoesyourchilddowithotherchildren?(playing,makingfriends,etc.)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Doesyourchild: Sharetoyseasily?☐Yes/☐No Followrulesofagame?☐Yes/☐No Havea"bestfriend"?☐Yes/☐No Joinotherkids'play?☐Yes/☐No Getbullied?☐Yes/☐No Bullyothers?☐Yes/☐NoIfyouthinkyourchildhasanyofthefollowingmorethanmostchildrenhisorherage,pleasecheckthebox,indicatehowofteninthemargin,anddescribetriggersorotherdetailsfurtherbelow:□Tantrums(rages,meltdowns) Sadness/crying□□Suddenrapidmoodswings Irritability/crankiness□□Aggression–physicalorverbal Lowselfesteem□□Disrespectforauthorityfigures Selfblame,guilt□□Inflatedsenseofownpowers,worth Failstoenjoythingsthatshouldbefun□□Fearless,risktaking Helpless,unmotivated□□Needslittlesleep,nevertired Fatigue,sleepstoomuch□□Precocioussexualinterest/behavior Eatstoomuchortoolittle□□Canbe“charming”whenwantstobe Talksaboutdeathorwishingneverborn□□Manipulatesothersforowngain □Generallynervous Rituals/compulsions□□Specificfears/worries Obsessions/fixations□□Shyoranxiousaroundotherpeople Physicalcomplaints□□Perfectionism/performanceanxiety Avoidsspecificsituations□□Panicattacks Over-reactstosounds,tastes,textures□□Troublesleeping Accidentswithbowels/urine□□Unusualinterests,withlotsoffactualknowledge Rigid,stubborn□□Off-topic,insertsinterestsintootherconversations Repetitiveoroddmovements□□Goesinto"lecturemode"evenwhenothersnotinterested Playseemsrote,repetitive□__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DEVELOPMENT & BEHAVIOR:

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Howdoyouthinkyourchildcomparestootherchildrenthesameageinthefollowingareas?Checkthelastcolumnifyouarenotsureorthechildistooyoungforthatskill.

DevelopmentalareaFar

BehindSlightlyBehind

Aboutthesame

Slightlyahead

Wellahead

Notsure/tooyoung/comments

Learning Reading Writing Math Science SocialStudies Art Music Handlingchores Communication/talking Followingdirections Mobilityorwalking Athletics/sports Selfcarelikefeeding,dressing,bathing

Whatnewskill(s)hasthechildlearnedinthepastyear?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Whatskill(s)hasthechildstruggledtolearninthepastyear,despiteattemptsatteaching?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Whatservicesorsupportsisthechildgettingnow?Checkallthatapplyandindicatehowoftenforhowlonginthemargins

SchoolServices:□IEP□504plan Servicesoutsidetheschool:□Mainstreamclasswith"inclusion"or"push-in"academichelp Tutoring□□Mostlymainstreamclasswith"pull-out"academichelp SpeechTherapy□□SpecialDayClass(SDC)forlearningorintellectualdelays OccupationalTherapy□□SDCforbehavioral/emotionaldisturbances PhysicalTherapy□□SDCforautismspectrumdisorders Psychotherapy/Counseling□□BehavioralPlan HomeBehavioralTherapy□□SocialSkillsgroup Socialskillsgroup□□SpeechTherapy RegionalCenterservices□□OccupationalTherapy Other(specifybelow)□□PhysicalTherapy _____________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICAL HISTORY:

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Anyproblemsduringpregnancy?__________________________________________________________Anyproblemsduringlabor/delivery?______________________________________________________Anyproblemsinnewbornnursery?________________________________________________________Agewhenyourchildfirstcamehomefromnewbornnursery?____________________☐days/☐weeksAnyproblemsgrowingorgainingweightduringthefirst6monthsoflife?☐Yes/☐No

Listanyofthefollowingyourchildhasexperienced(uselinesbelowtoprovidemoredetails):Hospitalizations

reason,length,approx.ageordateSurgeries

reason,type,approx.ageordateMajorillnessorinjurytype,approx.ageordate

Hasyourchildsufferedfrom: Listanymedicationsoralternativetherapies□Asthmaorrecurrentwheezing/bronchitis yourchildtakesregularlybelow:□Frequentinfections _______________________________________□Concussions _______________________________________□Allergies(listbelow) _______________________________________□Otherchronicillness(listbelow) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Visiontestedinlast3years? ☐No ☐Passed/☐Failed ☐wearsglasses/contactsHearingtestedinlast3years? ☐No ☐Passed/☐Failed ☐useshearingaideHashadallimmunizations?☐Yes/☐No Ifnot,why?_______________________________________REVIEWOFSYMPTOMS:Ifyouhaveconcernsaboutsymptomsnotcoveredaboveinanyofthebodyareasorfunctionsbelow,pleasechecktheboxanddescribeatthebottomofthepage.☐Generalhealth,energy,growth,orweight. ☐Skin,includingeczema,birthmarksorrashes☐RecurringFevers,chills ☐Immunity/frequentinfections☐Mouthorteeth ☐Endocrine/hormones☐Lungs/Breathing ☐Bloodorhematologic☐Heartorcardiovascular/circulation ☐Toiletingorgenitourinary☐Frequentconstipationordiarrhea ☐Muscles/bones/joints☐Recurrentvomitingorstomachaches ☐Neurologic,staringspells,shaking,orseizures____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Weightatbirth?____________☐lbs-oz/☐gm Bornneartheduedate(atterm?)☐Yes/☐No☐BornbyC-sectionbecause_______________ Ifno,______weeks☐Early/☐Late

FAMILY & SOCIAL HISTORY:

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Whoisinyourfamily? Athome? Age Name Education OccupationParent1 ☐Yes/☐No Parent2 ☐Yes/☐No Sibling1 ☐Yes/☐No Sibling2 ☐Yes/☐No Sibling3 ☐Yes/☐No Other ☐Yes/☐No Other ☐Yes/☐No Other ☐Yes/☐No Other ☐Yes/☐No

Checkanythatapply: ☐previouslyinfostercare ☐fosterchild ☐adoptedatage_____ Parents: ☐divorced ☐separated ☐nevermarriedorlivingtogether

Hasyourfamilyeverhadasignificantstress,trauma,orlossthatyouthinkmayhaveimpactedyourchild?☐Yes/☐NoPleasebrieflydescribewhat,when,andisitoverorongoing?__________________________________________________________________________________________________________________________________________________________________________Tothebestofyourknowledge,haveanybloodrelatives(evendistantones)hadanyofthefollowing?Condition Sideofthefamily?(circle) Who?#,Relationshiptochild?Developmentaldelay/intellectualdisability Mom's–Dad's–Both LearningdisabilitiesorDyslexia Mom's–Dad's–Both ADD,ADHD,hyperactivity Mom's–Dad's–Both Autismspectrumdisorders Mom's–Dad's–Both Seizuredisorder/epilepsy Mom's–Dad's–Both Cerebralpalsyormusculardystrophy Mom's–Dad's–Both TicsorTourettesyndrome Mom's–Dad's–Both Speechproblemsorstuttering Mom's–Dad's–Both Geneticdisorder(suchasDownSyndrome) Mom's–Dad's–Both Birthdefects(suchascleftpalate,spinabifida,congenitalheartdisease,etc.)

Mom's–Dad's–Both

Unexplainedsuddendeath Mom's–Dad's–Both Depression/Anxiety Mom's–Dad's–Both BipolarDisorder Mom's–Dad's–Both ObsessiveCompulsiveDisorder Mom's–Dad's–Both SchizophreniaorPsychosis Mom's–Dad's–Both Criminalordomesticviolence Mom's–Dad's–Both Addictionoralcoholism Mom's–Dad's–Both ADDITIONALINFORMATIONIsthereanythingelseyouwouldlikeustoknowpriortothevisit?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thankyouforcompletingthisform.Pleasereturnittoourofficepriortothevisit.