Special Child History Form

Therapist: ______________________
Child Name: ___________________ Date: ______________
Age: _______
Gender: _____________
Date of birth: _____________
No of siblings: _______ brothers ______ Sisters _______ Order: __________
Contact Number: ___________________ Email: ____________________ Postal add:

_________________________________________________________________________________________
Father Name: __________________ Occupation: _______________ ____ Age____ Income: _______
Mother Name: __________________ Occupation: _______________ ____ Age____ Income: __________
Age at time of Marriage

Type of Marriage
Father: ___________
Cousin: Out of family
Mother: ___________
Relatives Others
Any disability / Disorder

Family system
Father: _________________________
Joint: Divorced
Mother: _________________________
Family: __________________________ Nuclear Foreigner
Sibling’s details
1st born: Name _______________ Age: _____ any problem: ________________________
2nd born: Name _______________ Age: _____ any problem: ________________________
3rd born: Name _______________ Age: _____ any problem: ________________________
4th born: Name _______________ Age: _____ any problem: ________________________

Presenting Problem (Symptoms)
Symptoms Tick Symptoms Tick Symptoms Tick
Poor interaction (Ambiguous

Irritable mood Weak hygiene Management
speech, multiple meaning speech)
Slow learning or poor Deficit in emotional and social
Language problem
academics domain
Illogical or no Unable to describe a
Deficit in non-verbal communication
Reasoning topic or series of event
Poor judgment Reduced Vocabulary Poor or weak eye contact
Difficulty in sound
Poor communication Repetitive words
production
Poor social Disturbed or Poor social
Imaginative play (Alone)
participation Participation
Dependent living Stuttering or stammering Repetitive motor movements
Unusual interest in sensory aspect

Fixative interest Hyper activity / impulsive
of environment
Excessive smelling or Visual fascination with Fails to give close attention to
touching of objects lights or movements details
Avoid /Difficulty in organizing task
Careless mistakes Attention deficit
and activities
Easily distracted by Forgetful in daily Poor or weak self-management /
extraneous stimuli activities self-care / leisure and play
Inaccurate or slow
Difficulty with spelling Difficulty with written expression
effortful word reading
Difficulty mastering Clumsiness as well as slowness and
Difficulty with
numbers sense number inaccuracy of performance in motor
mathematics reasoning
facts and calculations skills
Purposeless motor
behavior (Hand Repetitive motor
Non rhythmic motor movement or
shaking, waving, self- behavior (May result in
vocalization (Tic)
biting, hitting own self injury)
body)
Separates easily from
Overly talkative Nightmares
parents
Cries easily Temper tantrums Nervous and sensitive

Presenting Problem (Details)
1. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Onset of a Problem
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Q) - Does child has any preferences in food
____________________________________________________________________________________
Sleep difficulty?
____________________________________________________________________________________
Q) - Is child sensitive to touch / sound/ pain
_____________________________________________________________________________________
Languages Spoken at Home With whom child spend most time
Primary others
How child tell his/her needs Does child understand when spoken?
Pointing / Gestures Clearly Need Assistant
Sound Confused
Single word Short phrases Little understanding

Age of playmates Age and procedure of toilet training
Older than him/her Strict
Younger than him/her Lenient
Same age Proper
Siblings Age _____________
Describe play of child
_____________________________________________________________________________________
_____________________________________________________________________________________
Does child give response to strangers?
____________________________________________________________________________________
Does child aware of his/her problems? If yes than how
_____________________________________________________________________________________
Other family members living with child and their behavior towards him/her (Name/Age/relation)
_____________________________________________________________________________________
At what age were you first concerned about your child problem?
____________________________________________________________________________________
How do you feed? How do you appreciate? How do you punish?
Strict No appreciation No punishment
Careless Avoiding Avoiding
Over caring Over appreciation Over Punishing
Over feeing proper Proper Proper
With whom child sleep (if separate then at what age he started sleeping separate)
Developmental History
S.no Time Duration Statement Tick
1 Pregnancy duration: 280 days or 40

Natural birth on time
weeks
2 Pregnancy duration: 37 weeks Preterm or premature baby
3 Pregnancy duration: 34-37 weeks Moderately Preterm
4 Pregnancy duration: 23-28 weeks Extremely preterm
5 Pregnancy duration: over 42 weeks Overdue
Birth Procedure
Normal At home
Cesarean Dai
Hard Under Doctor

If birth is before time: 37 weeksAny Trauma
Breach any other _______________
S.no Time Duration Tick Tick
1 Breathing problem Yes No
2 Low blood sugar Yes No
3 NICU Yes No
4 Feeding problem: sucking & swallowing Yes No
5 More often readmitted to hospital Yes No
6 First Cry of baby On Time Late
Post-Partum depression: ____________________ Birth weight: ___________

Any illness during pregnancy
Any miscarriages
Any medication during pregnancy
Any stress or trauma during pregnancy
Post Natal History
Medical history (Provide ages at which child suffered any of following illness)
Jaundice ____________ Allergies_______________ Infection _____________
Hemorrhage _________ Asthma ________________ Bronchitis ___________
Chicken Pox _________ Colds _________________ Convulsions __________
Dizziness ____________ Ear Infections __________ Headaches ____________
High fever ___________ Measles _______________ Mumps ______________
Pneumonia ____________ seizures _______________ Sinusitis _____________
Tinnitus _______________ Tonsillitis _____________ Constipation _________
Epilepsy ____________ any hearing problem_______ Medication_________
Any medication
1. _____________________________________ Reason ______________________________

2. _____________________________________ Reason ______________________________
3. _____________________________________ Reason ______________________________
4. _____________________________________ Reason ______________________________
5. _____________________________________ Reason ______________________________
Miles stones: On time Delay still late

General Observation of a child
 Eye contact: ___________________________________________________________________
 Alertness: _____________________________________________________________________
 Sitting span: ___________________________________________________________________
 Socialization: __________________________________________________________________
 Cleanliness: ____________________________________________________________________
 Dressing: _____________________________________________________________________
 Postures: _____________________________________________________________________
 Behavior : _____________________________________________________________________
Any schooling
Batteries to apply
Indication of disorder / tentative diagnosis
__________________________________________________________________________________
Summary
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Special Child History Form

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Special Child History Form

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Therapist: ______________________

Child Name: ___________________ Date: ______________

Date of birth: _____________

No of siblings: _______ brothers ______ Sisters _______ Order: __________

Contact Number: ___________________ Email: ____________________ Postal add:

Father Name: __________________ Occupation: _______________ ____ Age____ Income: _______

Mother Name: __________________ Occupation: _______________ ____ Age____ Income: __________

Age at time of Marriage

Any disability / Disorder

Family: __________________________ Nuclear Foreigner

1st born: Name _______________ Age: _____ any problem: ________________________

2nd born: Name _______________ Age: _____ any problem: ________________________

3rd born: Name _______________ Age: _____ any problem: ________________________

4th born: Name _______________ Age: _____ any problem: ________________________

Poor interaction (Ambiguous

Poor judgment Reduced Vocabulary Poor or weak eye contact

Dependent living Stuttering or stammering Repetitive motor movements

Unusual interest in sensory aspect

Cries easily Temper tantrums Nervous and sensitive

Q) - Does child has any preferences in food

Q) - Is child sensitive to touch / sound/ pain

Languages Spoken at Home With whom child spend most time

Single word Short phrases Little understanding

Older than him/her Strict

Younger than him/her Lenient

Same age Proper

Siblings Age _____________

Describe play of child

Does child give response to strangers?

Does child aware of his/her problems? If yes than how

How do you feed? How do you appreciate? How do you punish?

Strict No appreciation No punishment

Careless Avoiding Avoiding

Over caring Over appreciation Over Punishing

Over feeing proper Proper Proper

S.no Time Duration Statement Tick

1 Pregnancy duration: 280 days or 40

3 Pregnancy duration: 34-37 weeks Moderately Preterm

4 Pregnancy duration: 23-28 weeks Extremely preterm

5 Pregnancy duration: over 42 weeks Overdue

Hard Under Doctor

S.no Time Duration Tick Tick

1 Breathing problem Yes No

2 Low blood sugar Yes No

4 Feeding problem: sucking & swallowing Yes No

5 More often readmitted to hospital Yes No

6 First Cry of baby On Time Late

Post-Partum depression: ____________________ Birth weight: ___________

Any medication during pregnancy

Any stress or trauma during pregnancy

Post Natal History

Jaundice ____________ Allergies_______________ Infection _____________

Hemorrhage _________ Asthma ________________ Bronchitis ___________

Chicken Pox _________ Colds _________________ Convulsions __________

Dizziness ____________ Ear Infections __________ Headaches ____________

High fever ___________ Measles _______________ Mumps ______________

Pneumonia ____________ seizures _______________ Sinusitis _____________

Tinnitus _______________ Tonsillitis _____________ Constipation _________

Epilepsy ____________ any hearing problem_______ Medication_________

1. _____________________________________ Reason ______________________________

Miles stones: On time Delay still late

 Eye contact: ___________________________________________________________________

Child Name: _____ Date:

No of siblings: ___ brothers Sisters _ Order: ______

Contact Number: _ Email: __ Postal add:

Father Name: __________ Occupation: _ Age Income: _

Mother Name: __________ Occupation: _ Age Income: ____

1st born: Name _____________ Age: _ any problem: ______________________

2nd born: Name _____________ Age: _ any problem: ______________________

3rd born: Name _____________ Age: _ any problem: ______________________

4th born: Name _____________ Age: _ any problem: ______________________

Post-Partum depression: __________ Birth weight: _

Jaundice ____ Allergies_ Infection _______

Hemorrhage _ Asthma Bronchitis ___

Chicken Pox _ Colds _ Convulsions __

Dizziness Ear Infections Headaches __

High fever ___ Measles _ Mumps ________

Pneumonia ____ seizures _ Sinusitis _______

Tinnitus _________ Tonsillitis _ Constipation ___

Epilepsy ________ any hearing problem_ Medication_______

1. _______ Reason