Child Developmental Questionnaire

Mitchell Rosen, LMFT

43537 Ridge Park Drive, Suite 100

Temecula, CA 92590

(951) 541-3158
Child Developmental History

Use Separate Form for Each Child
Full Name of person completing this form:

First Name Last Name
Relationship to Child
If other, explain:
Child's Name

First Name Last Name
Date of Birth

Month Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone

- Area Code Phone Number
Name, Address, and Phone Number of School including teacher and grade
Child is presently living with:

Natural Mother Natural Father Stepmother Stepfather Step-Parent without marriage Adoptive Mother Adoptive Father Foster Parent Guardian Other
If other, please explain:
Name and relationship of every person living in the home with the child(ren):
Please state in detail any concerns you have about each child's emotional and/or physical health:
Childhood History
Duration of Pregnancy
Birth Weight
Type of Delivery
Condition of Child at Birth
If child was adopted, what were the circumstances, age of child at adoption, and date of adoption?
At what age was child toilet trained and were there any problems?
At what age did child begin to speak and were there any problems with speech?
To the best of your knowledge, did the biological mother use alcohol or drugs during pregnancy?
Please list names, ages, and addresses of all siblings:
Please list child's present height and weight
Date of most recent medical exam and findings:
Please list name, phone number, and contact information for this child's pediatrician:
Does the child currently take any medications? If so, for what condition and what is the dosage and frequency?
Is the child current with all immunizations? Why or why not?
Date of last dental exam and contact information for dentist?
Has the child had any serious illnesses or injuries? If yes, please explain in detail:
Does the child wear any prosthetic devices including hearing aids, braces, glasses, or contact lenses?
Does the child have any speech or hearing problems? If yes, please explain in detail:
Please mark if the child has ever had issues with:

Head Banging Seizures Nightmares or Night Terrors Thumb Sucking Bed Wetting Soiling Excessive Nervousness or Crying Rocking Sleep Walking Stuttering or Stammering Tics (involuntary movements) Angry Outbursts or Problems with Anger Nail Biting
Any additional issues or concerns not listed above:
How would you describe your child's physical health, please be detailed:
Has your child ever received counseling or therapy or been recommended for either? Please describe in detail including reasons, provider, contact information for provider, frequency and if it is still ongoing?
How old was your child when they entered school?
Have any teachers or administrators expressed concerns about your child and what were they?
Has your child ever skipped a grade or been retained? At what age and what was the reason?
I hereby swear under penalty of perjury the facts contained in this questionnaire are true and accurate to the best of my recollection.
Electronic Signature
Date
Case Name
Should be Empty:

Child Developmental History

Childhood History