Health And Developmental History Initial Assessment Form Page 2
ADVERTISEMENT
1
2
3
4PRENATAL/DELIVERY/NEWBORN HISTORY
Pregnancy
Date prenatal care started ______ weeks
Mother’s age at time of delivery ______
Medications during pregnancy ____________________
Was pregnancy essentially normal?
Yes
No
Pregnancy Issues:
Elevated blood pressure
Preeclampia/Eclampsia
Gestational diabetes
Excessive nausea/vomiting
Other: ____________________________________________________
Delivery
Gestation at delivery ______ weeks
Vaginal
Caesarean Was labor induced
Yes
No
Delivery Issues:
Forceps
Malposition of fetus
Hemorrhage
Separation of placenta
Infection
Other: ______________________
Newborn Health
Baby’s birth weight ___ lbs ___ oz
Was baby normal and healthy?
Yes
No
Did baby cry immediately?
Yes
No
Newborn Issues:
Jaundice
Cyanosis
Resuscitation required
Birth injury ____________
NICU admission?
Yes
No
Duration: _________________
Reason: _________________
Other: _________________________________________________________________________________
DEVELOPMENTAL HISTORY
Did your child meet developmental milestones at a normal time?
Yes
No
Were any of the following milestones achieved later than normal?
Sitting alone
Feeding self
Crawling
Walking
Talking
Hopping
Climbing
Throwing
Catching
Coloring
Dressing self
Cutting
Toilet training
Shoe tying
HEALTH HISTORY & CURRENT HEALTH
Check all conditions that your child has a history of or currently has:
ADD
Ear/Hearing Problems
Paralysis
ADHD
Epilepsy/Seizures
Physical Disability _____________
Accident/Injury _______________
Eye/Vision Problems
Sensitivity to noise/touch
Anemia/Blood Disorder
Dizziness/Unconsciousness
Skin Problems ________________
Asthma:
Frequent Strep Throat
Sleep Problems
Inhaler used?
Yes
No
Genetic Disorder ______________
Urinary Problems
Bowel Problems ______________
Headaches/Migraines
Food Allergies:_____________
Cancer ______________________
Heart Problems
Epi-Pen at home?
Yes
No
Cerebral Palsy
Hepatitis
Medication Allergies: ___________
Diabetes Type 1
Hyperactivity
Seasonal/Environmental Allergies
Diabetes Type 2
Intestinal/Stomach Disorder
Other __________________
Please provide detail for any listed conditions: ____________________________________________________
__________________________________________________________________________________________
Has your child ever had surgery?
Yes
No Date: ___________
Reason: _______________________
Has your child ever been hospitalized?
Yes
No Date: ___________
Reason: _______________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical