DEVELOPMENTAL / MEDICAL HISTORY FORM

Please fill out as completely as possible. This information will assist us in completing our initial assessment and in the development your child’s treatment plan.
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    PRENATAL HISTORY

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    BIRTH HISTORY

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    DEVELOPMENTAL HISTORY

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    When did your child achieve the following? Include AGE and COMMENTS
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    INFANCY AND EARLY CHILDHOOD

    Fussy
    Good, not demanding
    Lethargic
    Quiet
    Passive
    Active
    Colicky
    Difficult to calm
    Cried easily
    Trouble sleeping
    Liked being held
    Disliked being held
    Floppy when held
    Tense when held
    Liked being on stomach
    Enjoyed bouncing
    Enjoyed car rides
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    MEDICAL HISTORY

    HEALTH CONDITIONS
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    HELP US GET TO KNOW YOUR CHILD AND FAMILY

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    Please describe the challenges or concerns you have about your child in the following areas:
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    Person completing form
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