HUFFMAN PSYCHOLOGY, PLLC
Jennifer L. Huffman, Ph.D., ABPP-CN and Associates
Clinical Psychology and Neuropsychology Services
CHILD HISTORY FORM
For Office Use Only: Interview held on from to with
Instructions: Please answer all of the following questions to the best of your ability. Notes
Child’s name: _______________________________________ Date: ____________________________
Address: ___________________________________________ Date of birth: ___________ Age: _____
___________________________________________________ Sex: Male Female Other
Home phone: _______________________________________ Work phone: _____________________
Cell phone/other phone: _______________________________ Email: __________________________
Name of person completing form: ________________________ Relationship to child: _______________
Child’s primary care physician, address, and phone: ___________________________________________
_____________________________________________________________________________________
Referral Information
Who referred you for an evaluation/psychological services? ____________________________________
What are you hoping to gain from these services? ____________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
In your opinion, what is the major cause of this child’s difficulties? ______________________________
_____________________________________________________________________________________
Describe some of this child’s strengths: ____________________________________________________
_____________________________________________________________________________________
Describe some of this child’s weaknesses: __________________________________________________
_____________________________________________________________________________________
Do caregivers agree about the nature and causes of the problem? ________________________________
Pregnancy and Birth History
Child is: biological adopted (at age _________) foster
Was this child a planned pregnancy? No Yes
Was the mother under a doctor’s care? No Yes
Number of previous pregnancies: _______ miscarriages: _______
Check any of the following health complications during the pregnancy.
Fertility problems Vaginal bleeding Toxemia
High blood pressure Gestational diabetes Trauma
Fever/rash (e.g., flu, measles) Emotional problems Abnormal weight gain
Anemia Excessive swelling Excessive vomiting
Blood incompatibility Smoking Alcohol
Illicit drugs Medications Other: ________________
Hospitalization during pregnancy: Reason: _______________________________________________
X-rays during pregnancy: What month? _________________________________________________
List any medications, tobacco use, alcohol use, or other drugs during pregnancy: ____________________
_____________________________________________________________________________________
4572 S Hagadorn Rd, St 2G East Lansing, Michigan 48823
Tel. 517.337.9554
[email protected]Fax: 517.337.9545 www.hpsych.com
Age of mother: _______ and father: _______ at delivery Age of mother at birth of first child: ______
Birth weight: _______ lbs. _______ oz. Length of pregnancy: _______ weeks
Length of labor: _______ hours Apgar scores: ________________________
Delivery was: vaginal Cesarean (reason ____________________________________________)
Check any of the following complications during birth.
Breech birth Cord around neck Meconium staining
Lacking oxygen Forceps used Labor induced
Other: Describe: ____________________________________________________________________
Jaundiced: Bilirubin lights? No Yes If yes, how long? ____________________________
Did baby breathe spontaneously? No Yes Oxygen required? No Yes
Length of stay in hospital: Mother: _______ days Child: _______ days
Medical problems after discharge (e.g., jaundice, fever, transfusion, surgery)? ______________________
_____________________________________________________________________________________
Any problems in first few months? No Yes Explain: ___________________________________
Did mother experience postpartum (after birth) depression? No Yes
Describe this child’s temperament as an infant: ______________________________________________
Developmental History
Motor
Age sat alone: _________ crawled: _________ stood alone: _________ walked alone: _________
Was this child slow to develop motor skills or awkward compared to siblings/friends (e.g., running,
skipping, climbing, playing ball, handwriting)? ______________________________________________
Handedness: right left both (explain) ___________________________________________
History of physical therapy? When? ____________________________________________________
History of occupational therapy? When? ________________________________________________
Speech/Language
Age spoke first word: ________ put 2-3 words together: ________ spoke in sentences: ________
Oral motor problems (e.g., late drooling, poor sucking, poor chewing)? Describe: ________________
_____________________________________________________________________________________
Speech delay/problems (e.g., stutters, difficult to understand)? ________________________________
_____________________________________________________________________________________
History of speech/language therapy? When? _____________________________________________
Was this child slow to: learn alphabet? name colors? count?
Other language spoken in home (besides English)? _________________________________________
Toileting
Age when toilet trained: _________________________________________________________________
Problems with bed wetting? Until what age? _____________________________________________
Urine accidents? Until what age? ______________________________________________________
Soiling accidents? Until what age? _____________________________________________________
Current wetting or soiling problems? Explain: ____________________________________________
How old was this child when you first became concerned about his/her social/emotional/behavioral
functioning? __________________________________________________________________________
2
Medical History
Check any that apply and indicate age.
Failure to thrive Febrile seizures Epilepsy
Staring spells Lead poisoning Toxic ingestion
Meningitis Encephalitis Asthma
Allergies Diabetes Loss of consciousness
Stomach pain Vomiting Headaches
Constipation Urination problems Accident prone
Frequent ear infections Sleep problems Eating problems
Tics/twitching Repetitive movements Impulsivity
Temper tantrums Nail biting Clumsiness
Head banging Self-injurious behavior Rocks back and forth
Has vision been checked? No Yes Any problems? __________________________________
Has hearing been checked? No Yes Any problems? __________________________________
History of ear tubes? No Yes
List serious illnesses/injuries/hospitalizations/surgeries.
Incident (explain) Age
________________________________________________________________ ____________________
________________________________________________________________ ____________________
________________________________________________________________ ____________________
Check if any of the following have been performed (list dates).
CT _______________________ MRI _________________ EEG ____________________
List results of these or other tests: _________________________________________________________
Describe head injuries (e.g., date, type, loss of consciousness, associated symptoms): ________________
_____________________________________________________________________________________
Current medications/supplements and reasons: _______________________________________________
_____________________________________________________________________________________
Is there a family history of (list problems and relationships of family members):
learning or attention problems? _________________________________________________________
___________________________________________________________________________________
psychiatric problems (e.g., depression, anxiety, schizophrenia, other mental illness)? _______________
___________________________________________________________________________________
alcoholism or substance abuse? _________________________________________________________
___________________________________________________________________________________
autism spectrum disorder or intellectual disability? __________________________________________
___________________________________________________________________________________
neurological illness (e.g., Alzheimer’s disease, Huntington’s chorea, Parkinson’s disease, epilepsy)? __
___________________________________________________________________________________
other medical illness (e.g., high blood pressure, cancer, diabetes, migraine headaches, heart disease)? __
___________________________________________________________________________________
3
Does anyone else in the family have a problem similar to this child’s reason for referral? _____________
_____________________________________________________________________________________
Family Information
Parent/Caregiver name: ________________________________________ age: _____ education: _____
Occupation: ___________________________ Employer: ____________________________________
Parent/Caregiver name: ________________________________________ age: _____ education: _____
Occupation: ___________________________ Employer: ____________________________________
Parents are: married separated divorced never married
Describe the nature of the current relationship between the parents (e.g., loving, friendly, civil,
conflictual, violatile): ___________________________________________________________________
Do the parents generally agree on child rearing strategies (e.g., discipline)? No Yes
Is this child closer to one parent than another? No Yes If yes, which? ______________________
If divorced, who has custody of this child? __________________________________________________
Describe the visitation arrangements: ______________________________________________________
List all brothers and sisters, and any other members of the household(s).
Age Sex Name/relationship to this child Living at home? Problems?
_____ -_____ _____________________________________ ________________ __________________
_____ -_____ _____________________________________ ________________ __________________
_____ -_____ _____________________________________ ________________ __________________
_____ -_____ _____________________________________ ________________ __________________
_____ -_____ _____________________________________ ________________ __________________
_____ -_____ _____________________________________ ________________ __________________
Is this child in a child-care setting? No Yes How many hours/day? _______
Has this child ever experienced death or separation from a loved one? No Yes
Explain: _____________________________________________________________________________
Social History
Does this child:
have difficulty relating to or playing with other children? No Yes
interact better with adults than children his/her own age? No Yes
have difficulty making/keeping friends? No Yes
understand gestures? No Yes
have a good sense of humor? No Yes
understand social cues well (e.g., knows when others are angry)? No Yes
have problems with peer pressure (e.g., alcohol or drug use)? No Yes
show a desire to please you? No Yes
Adaptive Functioning
Please list any chores or responsibilities this child has at home: __________________________________
_____________________________________________________________________________________
Describe screen media use: ______________________________________________________________
Psychological History
Please describe this child’s typical mood: ___________________________________________________
4
List any previous direct contact with any social agency, psychologist, or psychiatrist.
Name and type of professional Reason for services Dates
____________________________ _______________________________________ ________________
____________________________ _______________________________________ ________________
____________________________ _______________________________________ ________________
____________________________ _______________________________________ ________________
Academic History
Current school and address: ______________________________________________________________
Grade: _____ Placement: regular resource special education other
Any grades that were skipped or repeated? No Yes Explain: _____________________________
Check any of the following teachers have reported problems in.
Reading Attention/concentration
Spelling Behavior
Arithmetic Social adjustment
Writing
Describe any academic problems.
Preschool ____________________________________________________________________________
Kindergarten __________________________________________________________________________
Early elementary school (1st to 2nd) ________________________________________________________
Upper elementary school (3rd to 5th) ________________________________________________________
Middle school (6th to 8th) ________________________________________________________________
High school __________________________________________________________________________
Has this child been tested for special education? No Yes Results: _________________________
Does this child have an IEP? No Yes If so, describe services: ____________________________
_____________________________________________________________________________________
Additional Comments
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
