Patient History Form Page 6
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7Family Psychology
Associates
Has this child been sexually active?
Yes
No
If yes,
727.725.8820
please describe: ______________________________________________
DEVELOPMENTAL HISTORY: (Answer as best you can remember)
Motor Development (Sitting, Crawling, Walking):
Early
Normal
Delayed
Speech & Language:
Early
Normal
Delayed
Self-help Skills (Dressing, Brushing, Shoe tying):
Early
Normal
Delayed
Toilet Training:
Early
Normal
Delayed
Handedness:
Left
Right
Both
Eating Behavior
Overeats sugar/carbs
Eats too much
Picky
SENSORY CONCERNS:
Is your child sensitive to, or do they display, any of the following?:
Light
Touch
Rocking
Head banging
Sounds
Textures
Falling Spells
Sock seams/tags
Food textures/aversions
TEMPERAMENT (Infancy, Toddler, Preschool):
Check any that apply.
Shy or Timid
Fearful
Impulsive
Stubborn
Easy to Manage
Aggressive
Affectionate
Social
Easy-going
Outgoing
Underactive
Slow to warm-up
Curious
Into Everything
Overactive
Temper Outbursts
Destructive
Happy
Daredevil
Wanting to be left alone
More interest in things than people
Other(s) __________________________________
SCHOOL HISTORY
Do you believe your child understands directions and interprets situations as well as other
children his or her age? _______________________________________________________________________
If not, please describe: _______________________________________________________________________
How would you rate your child’s overall level of intelligence compared to other children?
Below Average
Average
Above Average
Additional Comments: _______________________________________
__________________________________________________________________________________________
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