Patient Flow Sheet Template Page 2
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4Developmental History – Please indicate your (or your child’s) history in relation to the following:
Prenatal and Birth
Yes
No
If yes, please provide details on page 4
Prenatal stress or injury
___
___
Prenatal drug/alcohol exposure
___
___
Prenatal tobacco exposure
___
___
Birth trauma (forceps, breech, Cesarean, etc.)
___
___
Anesthesia or pain medications at delivery
___
___
Anoxia (oxygen deprivation at delivery)
___
___
Premature / Late delivery
___
___
Medical complications post-partum
___
___
Birth weight: _______lbs _______ oz.s
Was the patient adopted?
___
___
If yes, at what age? ____________________
Growth and development – Please indicate:
On time
Early
Late
Walking (9-12 mo.s – 13-17 mo.s - > 18 mo.s)
________
_____
_____
Talking (20+ words @ 18-20 mo.s is typical)
________
_____
_____
Feeding self (18-24 mo.s is typical)
________
_____
_____
Jumping (25-28 mo.s is typical)
________
_____
_____
Walk stair unassisted (25-30 mo.s is typical)
________
_____
_____
Walk stair alternating feet (36 mo.s is typical)
________
_____
_____
Medical Conditions of Childhood:
Yes
No
Please indicate what condition(s)
Allergies and/or Food sensitivities
___
___
____________________________________________
Infections of the eyes, ears, or throat
___
___
____________________________________________
0
Fevers greater than 104
___
___
____________________________________________
Measles, Mumps, Rubella, Whooping Cough
___
___
____________________________________________
Reactions to medications or vaccinations
___
___
____________________________________________
Trauma
Yes
No
If yes, please provide details (age at trauma)
Loss of consciousness for any reason
___
___
____________________________________________
Accidents requiring ER or doctor visit
___
___
____________________________________________
Serious illness requiring hospitalization
___
___
____________________________________________
Any infection of the Central Nervous System
___
___
____________________________________________
Any disease of the CNS (MS, Lupus, etc.)
___
___
____________________________________________
Accidental overdose or poisoning
___
___
____________________________________________
Intentional overdose
___
___
____________________________________________
Stroke /Cerebral tumor or cyst
___
___
____________________________________________
Chemotherapy or general anesthesia
___
___
____________________________________________
Are you a combat veteran?
___
___
____________________________________________
Death in the family or close friend
___
___
____________________________________________
Divorce / Remarriage
___
___
____________________________________________
Sexual / Verbal / Physical / Emotional Abuse
___
___
____________________________________________
Brain & Behavior Associates qEEG Patient Flow Sheet
Page 2
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