270 Farmington Avenue
Suite #344
Farmington, Connecticut
06032-1909

Joseph F. Kulas, Ph.D., ABPP

Board Certified Clinical Neuropsychologist
Board Certified Subspecialist
Pediatric Neuropsychology

Phone: (203) 805-8527
Fax: (888) 494-0373
JosephKulas.PhD@neuropsychologyct.org
npsych.us

Developmental History Form

Child's Name

Date of Birth

Address

Phone

School

Grade

Parent's Information

Parent / Guardian 1		Parent / Guardian 2
Name		Name
Occupation		Occupation
Education		Education

This is your Biological Adopted Foster child

Are there significant family or marital conflicts?

No Yes

Name of the child's legal guardian(s)

Household Members (reside with child)

Full Name	Sex	Date of Birth	Age	Grade	Relationship

Other Immediate Family Members (do not reside with child)

Full Name	Sex	Date of Birth	Age	Grade	Relationship

Reason for Evaluation

Reason(s) you are requesting this evaluation

History of Treatment: Therapies / Evaluations

	Psychology / Psychiatry	Occupational Therapy	Physical Therapy	Speech / Language
Treatment Date(s)
Treatment Provider
Evaluation Date(s)
Evaluation Provider

Does your child receive special services at school?

No Yes 504 IEP

Current medical diagnoses

No Yes

Current psychiatric diagnoses

No Yes

Current speech diagnoses

No Yes

Pregnancy and Birth History

1. Age of mother at delivery

2. Were there problems becoming pregnant?

No Yes

3. Did mother receive regular prenatal care?

No Yes

4. Mother's health during pregnancy (check all that apply)

Medications during pregnancy

Drank alcohol Smoked cigarettes Used recreational drugs

5. Delivery

Full term Premature

Weeks gestation (if premature)

Vaginal Cesarean

6. Birth weight – lbs

Birth weight – oz

7. Condition at Birth

OK Problems

Other birth problems

Developmental History

1. Temperament (check all that apply)

2. Motor Milestones

Age sat alone

Age crawled

Age walked alone

3. Language Milestones

Age spoke first word

Age put 2 words together

Age put 3 words together

4. Toilet Training

Age training initiated – Bowel

Age training initiated – Bladder

Age training completed – Bowel

Age training completed – Bladder

5. Eating difficulties?

No Yes

6. Sleeping difficulties?

No Yes

7. Problems with separation from parent(s)?

No Yes

8. Behavior problems?

No Yes

Medical / Health

1. Physician Name

Phone Number

Physician Address

2. Is your pediatrician aware of this referral?

No Yes

3. Vision checked (date)

Vision problems

4. Hearing checked (date)

Hearing problems

5. Serious Illnesses / Injuries / Hospitalizations / Surgeries

Date	Incident (explain)

6. Medications (current and past)

Type / Name	Dose	Start Date	End Date

7. Prescribing Physician Full Name

Phone Number

8. History of Conditions

Condition	Yes / No	Additional Information
Febrile seizure	Yes No
Epilepsy	Yes No
Lead poisoning / toxic ingestion	Yes No
Asthma or allergies	Yes No
Head injury	Yes No
Loss of consciousness	Yes No
Abdominal pains / vomiting When do they occur?	Yes No
Headaches When do they occur?	Yes No
Frequent ear infections	Yes No
Sleeping difficulties	Yes No
Eating difficulties	Yes No
Tics / twitching	Yes No

Education

1. Days absent in past year

2. Skipped or repeated a grade?

No Yes

3. Teacher reported problems in (check all that apply)

Please explain

4. Academic Problems by Grade

Nursery

Kindergarten

1st Grade

2nd Grade

3rd Grade

4th Grade

5th Grade

6th Grade

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Social

My child plays with children his/her own age.

No Yes

My child engages in normal imaginative or pretend play.

No Yes

My child's play generally revolves around one particular theme with minimal variation.

No Yes

My child is willing to let others join in games and play situations.

No Yes

My child engages in parallel play (plays besides another but does not engage them).

No Yes

My child engages in cooperative play.

No Yes

My child gets along well with other children.

No Yes

Behavior

Please mark any boxes that describe your child:

Sensory-Motor

1. Hand Preference

Right Left None

2. Does your child:

Dislike certain food textures

No Yes

Chew on non-food items (shirt, pencil, etc.)

No Yes

Dislike touching certain textures (paste, etc.)

No Yes

Dislike getting dirty

No Yes

Dislike being touched

No Yes

Appear clumsy or off-balance

No Yes

Have trouble with eye-hand coordination

No Yes

Have an unusual posture / gait

No Yes

Have difficulty with handwriting or drawing

No Yes

Family Information

1. Overall health – Parent 1

Overall health – Parent 2

2. Significant events in the previous 2 years

Deaths

Move

Job transfer

Accidents / serious illness

3. Family History — please note relationship to child for any Yes

Include child's parents, grandparents, siblings, aunts, uncles, and cousins.

Is there any history of:	Biological Mother's Side	Biological Father's Side
Learning problems?	Yes No	Yes No
Reading problems?	Yes No	Yes No
Attention problems?	Yes No	Yes No
Stuttering?	Yes No	Yes No
Epilepsy or seizures?	Yes No	Yes No
Other neurologic disorders?	Yes No	Yes No
Diabetes?	Yes No	Yes No
Genetic or inherited disorders?	Yes No	Yes No
Other serious illnesses / health problems?	Yes No	Yes No
Emotional disorders?	Yes No	Yes No
Received / is receiving psychiatric treatment?	Yes No	Yes No
Hospitalized for an emotional problem?	Yes No	Yes No
Drug / alcohol addiction or abuse?	Yes No	Yes No
Attempted / committed suicide?	Yes No	Yes No
Violent behavior?	Yes No	Yes No

Completed By

Relationship to Child

Date

Completed By

Relationship to Child

Date

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