Family History

1. Name of the child:

2. Mothers Name:

Age: Session:
Date:
Age: Education:
Occupation:
3. Mothers Name:
Age: Education:
Occupation:
4. Type of Marriage: within Relations/Not Relations
5. Mother Tongue:
Languages Known:
6. Base: Rural / Urban / Semi urban
7. No. of Children
8. Birth Order of the child:
9. Parents: Seperated / divorced /either parent deceased (mention who)
10.Where does the child live:
11.Any kind of challenges present in the family:
12.If Yes, please mention the kind of challenges:
Birth / Medical History:
Prenatal:
13.Age of the mother when the child was born:
14.Any kind of malnutrition/ infection / hypertension / diabetes / epilepsy /
severe anemia / other
15.Any kind of injury / trauma (physical / emotional), exposure to x-rays / drugs /
medication, RH incompatibility, abortions (threatened / attempted / medical
termination)
Perinatal:
16.Place of delivery: home / hospital / nursing home
17.Nature of delivery: normal / caesarian / instrumental
18.Process of delivery: prolonged difficult labour / premature rupture of
membrane / other abnormal factors
19.Duration of pregnancy : pre mature / post mature
20.Birth cry: immediate / delayed / weak
21.Abnormal color at birth
22.Birth weight:
23.Head circumference: (micro / hydrocephalic)
24.Any medical attention given:
25.Oxygen deprivation during delivery:
26.Lack of resuscitation:
Post natal:
27.Any respiratory illness / meningitis / encephalitis/ infections
28.Severe malnutrition/ prolong illness / convulsions
29.Immunizations
30.Any kind seizures within 5 years of childs life yes/no

If yes, what was the reason for seizures: prolonged high fever / sudden high
fever & vomiting
Developmental history:
31.Ages when various developmental milestones emerged ( Head control,
turning over, crawling, standing walking, speech social smile)
32.Medication child is on, surgery done, therapy / treatments given in the past
33.Current treatment / medications child is on
Parental Needs / Recommendations
34.Parents concerns
35.Expectations from the child and professional
Emotional:
36.Does child express feelings?
37.What feelings? How?
38.Mode of managing feelings / claiming self
39.Response to encouragement
Health:
40.General health and hygiene
41.Any frequent infections
42.Diet, food allergies
43.Constipation
44.Sleep patterns
45.Any seizures
Sensory areas:
46.Vision
47.Hearing
48.Does the child have any unusual difficulties. Specify
49.Aids / adaptations used / required for either of the above
50.Any further referrals / check ups required
51.Hyper / hypo sensitivity to touch, smell, taste, sound, light
52.Seeking or avoiding vestibular
Self Care:
At what age child has become Dependent, partially dependent, independent in the
following activities
53.Eating
54. drinking
55.Toileting
56.Undressing / dressing
57.Does the child have unusual difficulties? Specify

58.Aids / adaptations used / required for any of the above.

Motor (Physical)
59.Posture / muscle tone
60.Balance
61.Mobility / gross motor skills
62.Hand function / fine motor skills
63.Aids / adaptations used / required for the above
64.Hand dominance (after 5 years)
65.Any therapy given
66.Any hyper active behavior: unusual Rocking, Spinning, Hand Flapping
Social (Relationships)
67.Interaction with care giver / family
68.Willingness to communicate
69.Social eye contact
Any behaviours inappropriate for age / behavior problems.
Play
70.Type of play child engages in
Had the child engaged in one or more of any of the following play activities
and if done so approximately at what age.
Solitary play (plays by himself / herself)
Pretend play imitating others
Parallel play (plays alongside others)
Stereotypic play (repetitive play i.e. arranging cars in a line, twirling
wheels of a car over & over)
Co-operative play ( playing with others, taking turns, sharing)
Organized play (playing games with rules)
Understanding:
71.Attention to play activity
72.Inattention or impulsivity inappropriate for age
73.What does child play with? Objects / toys / pictures / others
74.How does the child play? Grasping / mouthing / sorting / matching /
sequencing / others
75.Any aids / adaptations required to facilitate the play
76.Indicating for toileting, hunger, pain, thirst
Communication:
77.Does child listen / attend when spoke to?
78.Language comprehension in mother tongue, other languages
79.Mode of expression
Speech( clarity, length of sentence, tone of voice, language child uses)

Pre speech vocalizing

Non verbal ( Eye pointing / hand pointing / gestures / facial expression)
Does child use a Picture board, Alternative & Augmentative
communication?
What does child communicate? hunger, pain, thirst, toileting,
feelings, ideas, others.
Does child have a yes / no response

General
80.Does the child like to take more of pocket food, pizza, burger, cool drinks. If
others, please mention
81.Does the child sleep before 9 at night.
82.If the child sleeps late, what is the wake up time?
83.How many hours does the child sleep in general for a day?
84.How many hours does the child watch T.V.?
85.Is there, any restricted time for T.V. watching?
86.Can you help your child in his / her studies? Yes / No
87.If so, how much time can you spend with your child.
88.