Skip to main content
Menu
2 Convenient Locations
Home » Child History

Child History

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Name
  • PRESENT SITUATION

  • Does your child report any of the following?
  • SYMPTOM CHECKLIST

  • MM slash DD slash YYYY
  • After each symptom listed, circle the number that best describes how often you experience that particular problem.

    0 = Never, 1 = Seldom, 2 = Occasionally, 3 = Frequently, 4 = Always
  • SCHOOL HISTORY

  • DEVELOPMENTAL HISTORY

  • Check any the following which DID NOT occur at the expected time

  • FAMILY HISTORY

    OTHER MEMBERS OF FAMILY
  • Medical Problems (Diabetes, Blood Problems, Allergies, ect.)
  • IllnessRelationshipAgeTreatments and/or Complications 
  • Visual Problems (Cataracts, Glaucoma, Amblyopia, Turning Eye, ect.)
  • IllnessRelationshipAgeTreatments and/or Complications