DEVELOPMENTAL HISTORY Please indicate the approximate age in months for the following milestones: (example: walking 14 months): Sitting up _______ months Never ________ months Never Pulled to stand ________months Never trained ________ months Never Walked alone ________ months Never Dry at night ________ months Never words (mama, dada) ____months Never Spoke clearly ________ months Never Lost language ________ months Never Lost eye contact _______months Never MEDICATIONS Current Medications Medication Dose Frequency Start Date (month/year) Reason for Use Previous Medications: Last 10 Medication Dose Frequency Start Date (month/year) Reason For Use Nutritional Supplements (Vitamins/Minerals/Herbs/Homeopathy) Supplication and Dose Frequency Start Date (month/year) Reason for Use
SYMPTOM REVIEW Please check all current symptoms occurring or present in the past 6 months. STRENGTHS Accepts new clothes Cuddly Physically coordinated Happy Pleasant/easy to care for Sensitive/affectionate to be liked Responsible accurate pictures Sensitive to peoples’ feelings OK if parents leave Answers parent Follows instructions Pronounces words well Unusual memory Perfect musical pitch Good with math Good with computer Good with fine work Good throwing and catching Good climbing Strong desire to do things Swimming Bold, free of fear Likes to be held Likes to be swaddled SLEEP Sleeps in own bed Sleeps with parent(s) Awakens screaming/crying Awakes at Difficulty falling asleep Early waking Insomnia Sleeps less than normal Daytime sleepiness Jerks during sleep Nightmares Sleeps more than normal PHYSICAL Looks sick Glazed look Overweight Underweight Pupils unusually large Unusual long eye lashes Pupils unusually small Dark circles under eyes Red lips Red fingers Red toes Webbed toes Red ears Double jointed High arched palate Lymph nodes enlarged neck Head warm Head sweats sweats Abnormal fatigue Failure to thrive Cold all over Cold and feet Cold intolerance Hands/feet - very sweaty Head very hot/sweaty Night sweats Perspiration - odd odor SKIN Paleness, severe Fungus / fingernails Fungus / toenails Dandruff Chicken skin Oily skin Patchy dullness Seborrhea on face calluses Athletes foot Feet - stinky Diaper rash Odd body odor Strong body odor Acne Dark circle under eyes Ears get red Eczema Flushing Red face Sensitive to insect bites Stretch Blotchy skin Bugs love to bite you Cradle cap Dry Hair Dry Scalp Hair Unmanageable Bites nails brittle frayed pitted Nails soft Skin pale Dark birth mark(s) Easy bruising Inability to tan birth mark(s) Ragged cuticles Thickening finger nails Thickening toenails Vitiligo White spots or lines in nails Dry skin in general Feet cracking Feet peeling Hands cracking Hands peeling Lower legs dry Skin lackluster Itchy skin in general Itchy scalp Itchy ear canals Itchy eyes nose Itchy roof of mouth Itchy arms Itchy hands Itchy legs Itchy feet Itchy anus Itchy penis Itchy vagina DIGESTIVE Breath bad Increased salivation Drooling Cracking lip corners Cold on lips, face Geographic tongue (map-like) Sore tongue Tongue coated Canker in mouth Gums bleed Teeth grinding cavities Tooth with amalgam fillings
Sensitive to loud noise Sounds seem painful Tinnitus Acute sense of smell Examines by smell Intensely aware of odors Blinking Bothered by bright lights Distorted vision Conjunctivitis Eye crusting Eye problem Lid margin redness Examines by Fails to blink at bright light fans Likes flickering lights out of corner of eye Poor vision Puts eye to bright light or sun Strabismus (crossed eye) Fearful of harmless object Fearful of unusual events Unaware of danger Unaware of peoples’ feelings Unaware of self as person Upset if things change Upset of things aren’t right Adopts complicated rituals Car, truck, train obsession Collects particular things Draws only certain things Fixated on one topic Lines objects precisely Repeats old phrases Repetitive play/objects Finger tip squeezing Hates wearing shoes Insensitive to pain Likes head burrowed Likes head pressed hard Likes head rubbed Likes head under blanket Likes to be held upside down Likes to be swung in the air Very insensitive to pain Very sensitive to pain NEUROMUSCULAR Clumsiness Coordination Fine motor poor Gross motor poor Holds bizarre posture Hyperactivity Physically awkward Rocking Stiffens body when held Calf cramps Foot cramps Muscle pain Muscle tone Muscle twitches Fist clenching Jaw clenching Poor muscle tone/limp Tics Muscle tone low trunk Muscle weakness, atrophy Muscle tone low all over Tremors Cognitive delays Memory poor Poor attention, focus Slow and sluggish Expressive language delay SPEECH Never spoke words when excited Expressive language poor No answers simple questions Points to objects/can’t name Speech apraxia Does not ask questions Babbling Asks using “you” not “I” Answers by repeating question Receptive language poor Says “I” Says “no” Says “yes” Lost language @ 12-24 months Lost language after 24 months Scripting Stuttering to self Poor auditory processing Unusual of cry Uses one word for another Rigid behaviors Poor confidence Timid Corrects imperfections Tidy RESPIRATORY Pneumonia Bad odor in nose Breath holding Bronchitis Congestion chg. season Congestion in the fall Congestion in the spring Congestion in the summer Congestion in the winter Cough Post nasal drip Runny nose Sighing Sinus fullness Wheezing Yawning REPRODUCTIVE Girls: Early first period Boys: testicles Early breast development Early pubic hair vaginal odor URINARY Frequent urination Bed wetting age 4 Odd urinary odor Urinary hesitancy Urinary tract infections Urinary urgency Dry at OTHER Seizures - focal Seizures - generalized Seizures - mal Seizures - petit mal Unusual fast heart beat Heart murmur Headache Joint pains Leg pains Muscle pains
DAY _______ (Food, Drink, Exposure) Output (BM, Pee, Mucous, etc…) MOOD/Behavior Other Comments_______________________________________________________________________ Other ________________________________________________________________________________ DAY _________ Input (Food, Drink, Exposure) Output (BM, Pee, Mucous, etc…) MOOD/Behavior Comments______________________________________________________________________