Childhood History - Dr Christina van der Merwe
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Childhood History
Contact Information
Child's Name:
Date of Birth:
Age:
Sex:
Male
Female
Ethnicity:
Home Address:
City:
Province:
Postal Code:
Home Phone:
Cell Phone 1 (parent):
Cell Phone 2 (parent):
Child's schools and address:
Grade:
Special Placement (if any):
Child is presently living with:
Birth Mother
Birth Father
Stepmother
Stepfather
Adoptive Mother
Adoptive Father
Foster Mother
Foster Father
Other (specify):
Nonresidential adults involved with this child on a regular basis:
Source of referral:
Briefly describe your main concern regarding this child:
Birth Parents' Information
Mother
Occupation:
Business Phone:
Age:
Age at time of pregnacny with patient:
Highest Grade Completed:
Please describe any history of........
Learning difficulties:
Attention difficulties:
Behaviour difficulties:
Emotional/psychiatric difficulties:
Medical difficulties:
Prescriptions used for past or present psychiatric/psychological difficulties:
Have any of the birth mother's blood relatives experienced difficulties similar to those your child is experiencing? if so, describe:
Father:
Occupation:
Business Phone:
Age:
Age at time of pregnancy with patient:
Highest grade completed:
Please describe any history of........
Learning difficulties:
Attention difficulties:
Behaviour difficulties:
Emotional/psychiatric difficulties:
Medical difficulties:
Prescriptions used for past or present psychiatric/psychological difficulties:
Have any of the birth father's blood relatives experienced difficulties similar to those your child is experiencing? if so, describe:
Child's Siblings:
1. Name ___________________________________ Age _______________________________ Medical, Social, emotional or school problems
2.
3.
4.
5.
6.
Pregnancy Complications
Excessive vomiting
Yes
No
Hospitalisation required
Yes
No
Excessive staining/blood loss
Yes
No
Threatened miscarraige
Yes
No
Infection(s)(specify):
Toxemia
Operation(s)(specify)
Other illness(es)(specify):
Smoking during pregnancy
Yes
No
Number of cigarettes per day:
Alcoholic consumption during pregnancy:
Yes
No
Describe if beyond an ocasional drink
Medication taken during pregnacy:
Duration of pregnancy (weeks):
Smiled
Smiled
Early
Normal
Late
Sat without Support
Early
Normal
Late
Crawled:
Early
Normal
Late
Stood with support
Early
Normal
Late
Walked without support:
Early
Normal
Late
Spoke first words:
Early
Normal
Late
Said phrases:
Early
Normal
Late
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