Dosheen Cook, Ph.D.
ClinicAD
10631 Professional Circle, Suite A
Reno, NV 89521
Phone (775) 826-6218
Fax (775) 826-6271
Child Name:___________________________________
DOB:_____________________________________
REASONS FOR EVALUATION/THERAPY
Who referred your child?
Please describe the problems, questions or concerns for which you are seeking help at this time. Also, please
indicate when these problems were first noticed.
At what age were problems
first noticed
What do you think might be the reason for your child’s difficulties?
TEMPERAMENT/ CHILD’S PERSONALITY CHARACTER
Please indicate whether your child has shown any of the following behaviors. Explain, if possible.
 Excessive crying
 Talks about wanting to die
 Anxiety / nervousness
 Excessive worries
 Fears
 Rituals
 Odd behavior
 Odd thinking or speech
 Eating Problems
 Fidgets / Can’t sit still
 Interrupts frequently
 Fighting
 Frequent temper tantrums
 Destructiveness
 Defiance of authority
 Delinquent behavior
 Inappropriate sexual behavior
 Teases others Frequently
 Nightmares, night terrors, sleep walking,
talking in sleep
 Difficulty falling or staying asleep
Other Concerns:____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What are you hoping to have happen or gain from evaluation/therapy?
___________________________________________________________________________________________
Has your child had previous evaluations or treatments for your concerns?
If so, where and when? Please attach any available reports.
 Yes
 No
_
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What were their findings?
_
 Yes  No
Do you agree with their findings and recommendations?
Why?
_
MEDICAL HISTORY
PREGNANCY HISTORY
Note: This information relates to birth (biological) parent.
Mother’s age at delivery? ____________________
Did you recevie prenatal care?
Mother's health during pregnancy (check)
Good
Fair
No
Yes
Poor
Did mother drink alcohol during pregnancy?
No
Yes, if so, what kind and how often?
__________________________________________________________________________________________________
Did mother use any other types of drugs during pregnancy?
No
Did mother smoke cigarettes during pregnancy?
day?
Yes, if so, what kind and how often?
No
Yes, if so, how many packs per
BIRTH HISTORY
Where was the child born? Name of Hospital and Location (City, State, Country)
_
Length of pregnancy
Labor was (check one)
easy, no problems
_____________________________________________
Type of delivery:
Baby's position:
Natural (vaginal)
Head down (vertex)
difficult
C-section
Forceps
Vacuum
Induced / Augmented
Legs or bottom down (breech)
Were there any problems during labor or delivery?
Yes
No
If Yes, explain
Birth weight:
Length:
Head circumference
NEONATAL AND EARLY INFANCY HISTORY
Duration of mother's hospital stay
Duration of baby's hospital stay
Were there any problems while the baby was in the hospital?
(check)
Yes
No
If yes; the
reason(s)__________________________________________________________________________________________
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POSTNATAL HEALTH
List any accidents, injuries, chronic or severe illnesses, or medical problems your child has had that have required
frequent care by a doctor or follow-up by a specialist:
Reason
Date
Age
Doctor / Specialist
Hearing
Ear infections
Ear tubes
Hearing problems
Vision
 Vision problems
 Wears glasses or contacts
 Eyes turning in or out
List ALL medications child is taking at this time:
Name of medication
Dosage and Times Taken
Has child ever had a bad reaction to a medicine?
Benefits / Side effects?
Yes
No (explain)___________________________
DEVELOPMENTAL HISTORY
Current Weight:__________________________________ Height:___________________________
Have you ever been worried that your child's development was slower than it should be?
If yes, explain:
Yes
No
Have you ever been worried that your child has lost skills that he/she used to have?
If yes, explain:
Yes
No
We would like to have some more detailed information about your child’s development. On the next page please write the
age at which your child did each of the following. If you cannot recall exactly, please indicate early, normal, late, or
not achieved yet = NA. Sometimes using a “baby book” or remembering moves, birthdays, etc can be helpful.
MOTOR
Rolled over front to back
Sat without support
Crawled on hands and knees
Walked with no help
Ran well
USE OF HANDS
Reached for object and grabbed it
Finger fed
Picked up small things (e.g.,Cheerios) between 2
fingers
Scribbled
Age
Early
Normal
Late
NA
Typical Age
(months)
4-6
7-8
7-8
10-15
21
4-5
7-8
12
12-15
3
Age
Early
Normal
Used a spoon without spilling
Tied shoelaces
Wrote his or her name
LANGUAGE
Smiled Responsively
Babbled
Said “da-da” or “ma-ma”
Understood “No”
First word other than “mama” or “dada”
Pointed to named picture (“Show me the dog.”)
Pointed to 1 - 4 body parts
2 word phrases (“Let’s go”)
3 word sentences
Said first and last name
SOCIAL/GENERAL SKILLS
Laughed
Smiled and made faces at mirror
Played peek-a-boo
Imitated tricks such as waving
Undress self
Dress self
Pointed to show items of interest
Would bring items to show you
Toilet Trained: Day
Toilet Trained: Night
Late
NA
Typical Age
(months)
15-18
60-72
60
1-2
6
8-9
8-10
11-12
18
18-20
21
36
36
2-4
4
7-9
9
36
48
9-14
14
24-36
36-48
CURRENT SKILLS
Please check the column that best describes your child compared to other children of the same age:(for school age /
preschool children):
Skill or Ability
Throwing/catching
Running, jumping
Imaginary Play
Balance
Understanding
spoken instructions
Expressing self
verbally
Speaking clearly
Reading
Handwriting
Spelling
Math
Completing
homework
Building things
Self help, Dressing
self
Below Average
Average
Above Average
Not Sure
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Tying shoes,
buttoning, zipping
Ability to make
friends
Ability to keep
friends
SCHOOL HISTORY
Current School:
Grade:
School Phone Number:
Teacher (Main Classroom):
Special Ed or Resource Room teacher:
Type of class:  Regular
 Special education.
What special services he/she is receiving?________________________________________________________________
Has child ever been retained a grade or held back?
Grade
 No
 Yes (explain)
Check any problems child has had in school in the past compared to other typical students:
Unable to pay attention, stay
Problems with
Problems with
Special Education or
on task, or complete
learning, low or
behavior at school
Interventions
assignments
failing grades
attempted by school
Preschool
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh-Ninth
Ninth-Twelfth
SOCIAL HISTORY
PARENTS
Mother's name_________________________________________ Age _________
Occupation____________________________________________ Marital status___________________________
Check which applies:  Biological/birth
 Adoptive  Step  Foster  Other ______________
Father's name__________________________________________ Age _________
Occupation____________________________________________
Marital status___________________________
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Check which applies:  Biological/birth
 Adoptive  Step  Foster  Other _______________
With whom is child currently living (list members of household and primary caregivers)?
Name
____________________
____________________
____________________
____________________
____________________
____________________
Age
____
____
____
____
____
____
Relationship to patient
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
If parents are separated or divorced, who has custody of this child?________________________
How often does the other parent see this child? (check one)
 Weekly or more often
 Once or twice a month
 Few times a year
 Never
How long have the parents been separated?______________________
FAMILY HISTORY
Does anyone in the family have any of the following? Check all that apply, past or present.
Condition
Mother
Father
Sibling
Mother's
Family
Father's Family
Mental retardation
Learning disorder
Attention problems; hyperactivity
Depression
Suicide attempts
Anxiety disorder/panic attacks
Psychosis or schizophrenia
Obsessive-compulsive disorder
Alcohol or drug abuse
Tics or Tourette syndrome
Developmental Delays
Seizures
Autism
Birth defects or familial disorder
Cerebral palsy
Speech or Language Problem
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