RICKS CENTER FOR GIFTED CHILDREN
EARLY CHILDHOOD PROGRAM
Developmental Information
The following questionnaire is designed to help us understand your child’s developmental history. All
information received will be kept strictly confidential. Although complete information on each child would be
appreciated, we understand that some parents may choose not to answer or be unable to answer certain
questions. Please refer to baby books, old calendars or consult your family doctor for specific developmental
information about your child. If you have questions, please contact our Admissions Office at 303-871-3715.
Today’s Date ______________________
Day / Month / Year
Child's Name _____________________________________________
(First, Middle, Last)
Gender ___________________________
Date of Birth ____________________ Place of Birth _______________________________________________
(City, State/Country)
Prenatal History
Age of Mother at birth of child ___________
Age of Father at birth of child ______________
Birth Order ____________
Length of Pregnancy ____________________
Pregnancy Normal:
If no, please explain
Yes ______
No _______
_________________________________________________________________________
Perinatal History
Unusual exposure to
Radiation
___ Yes ___ No
Medication ___ Yes ___ No
Drugs
Any problems during delivery:
If yes, please explain
Alcohol
___ Yes ___ No
Cigarettes ___ Yes ___ No
___ Yes ___ No
___ Yes ___ No
________________________________________________________________________
APGAR Score: one minute __________
five minutes __________
(Scale of 1-10 based on color, breathing, heart rate, reflex, muscle tone)
Other assessment scores ________________________________________________________________________
(e.g. Denver Diagnostic Screening Test (DDST) or Pediatric Development Questionnaire (PDQ))
Birth Weight ________________ Length ______________
Healthy at Birth?
If no, please explain
Yes _____ No _______
_________________________________________________________________________
© 2015 Ricks Center for Gifted Children DQ
Early Developmental History
(Please indicate achievement age in years and months.)
Sat Alone
_____________
Rode Tricycle _____________
First tooth
_______________
Toilet Trained ______________
Toddled
_____________
Wrote first word ____________
Crawled
_____________
Rode Bicycle
_____________
First word
Scribbled
_____________
Walked Easily _____________
Learned to read _____________
First Step
_____________
Tied shoes alone ___________
Complete sentences _________
_____________
Additional unusual accomplishments: ___________________________________________________________
____________________________________________________________________________________________
What unique and/or interesting experiences has your child had? (i.e., special family times, travel, classes, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
Medical History
Hospitalizations:
Dates:______ to____ : (reason) _____________________________________________
Dates:______ to____ : (reason)______________________________________________
Other pertinent health related information: (e.g. allergies, diabetes, asthma etc.)
___________________________________________________________________________________________
___________________________________________________________________________________________
Please check the type of care your child had:
Years:
Sitter
Preschool Home
Daycare Other
(specify)
0-1
____
____
____
____
____
_______________
_______________
1-2
____
____
____
____
____
_______________
_______________
2-3
____
____
____
____
____
_______________
_______________
3-4
____
____
____
____
____
_______________
_______________
4-5
____
____
____
____
____
_______________
_______________
© 2015 Ricks Center for Gifted Children DQ
Approx. #hrs/wk