Child and Adolescent Clinical Assessment

Step 1 of 18

Current Date(Required)

Name of Child(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Current Weight

(in pounds)

Allergies(Required)

Drug Intolerances(Required)

(eg severe diarrhea, headaches, etc)

Current/Active Diagnosis (Problem List)

Pregnancy and Infancy History

Pregnancy History

Mother's age at birth

Father's age at birth

Total # Pregnancies

# Pregnancy for this child

# Premature Births

Please list any supplements/vitamins taken by mother during pregnancy.

# Miscarriages

Infertility Treatments if any

IVF Treatments if any

Was mother on birth control while pregnant?

Yes

Which kind?

If yes, what week gestation was it discontinued?

Please list any medicines taken by mother during pregnancy

Please indicate if mother experienced any medical illnesses during the pregnancy

Bacterial illnesses (UTI, GBS+, etc)

Bleeding/spotting

Eclampsia/ HELLP syndrome

Emotional distress/ extreme stress

Gestational diabetes

Hypertension (High Blood pressure)

Pre-eclampsia

Preterm labor

Recurrent yeast infections

Viral illnesses

Vomiting requiring medicines or hospitalization

Other

Other medical illness

How many alcoholic beverages per week consumed while pregnant?

Any dental work done while pregnant?

Yes

How many amalgams did mother have while pregnant?

Any occupational exposure to mercury or other toxins while pregnant?

Yes

Did mother receive a Rhogam injection during pregnancy?

Yes

Did mother receive Tdap or Flu shot during pregnancy?

Yes

Was there regular prenatal care while pregnant?

Yes

How many ultrasounds done?

Did mother have amniocentesis?

Yes

Was house occupied during pregnancy built before 1978 or have any renovation done during pregnancy?

Yes

Any special diets during pregnancy? (Vegan, organic, paleo, etc)

Yes

Types of fluids consumed during pregnancy (Well/tap water, caffeinated drinks, etc)

How frequently and what type of seafood consumed during pregnancy?

Foreign travel during pregnancy?

Yes

If yes, where?

Birth History

Duration of pregnancy with this child

Method of Delivery

Vaginal

Cesarean Section

VBAC

If Cesarean, was it emergency or planned?

Was labor induced?

Yes

Epidural?

Yes

Birth Weight

Birth Length

Birth Head Circumference

Apgar Scores (if known): 1 min

Apgar Scores (if known): 5 min

Please choose all of the following complications that apply to the delivery of the child:

Drop in fetal heart rate

Fetal distress

Meconium

Forceps required

Vacuum extraction

Cord around neck

Jaundice requiring phototherapy

Transient breathing difficulties

Temporary oxygen or breathing assistance but no NICU needed

Infections/ Fever

Other

Admitted to NICU

Other Complication(s)

If admitted to NICU

Antibiotics

Intubation/ Breathing tube

Pneumonia

Chronic Lung Disease

Feeding tube

Feeding difficulties

Necrotising enterocolitis (NEC)

Intraventricular Hemorrhage (IVH)

Seizures

Periventricular Leukomalacia (PVL)

Congenital Heart Disease/ Patent Ductus Arteriosus

Other

Other NICU Issues

Infancy Dietary History

Choose all that apply

Breast Fed

Expressed Breast Milk

Formula

Reflux?

Milk/ Formula Intolerances?

Colicky baby?

Infantile eczema?

Special diet/ restrictions required in first year of life?

How long breast fed?

How long expressed breast milk?

Forumula type and reason

Age when started formula

Require reflux medicines?

Yes

Which reflux medicine prescribed

Please explain any special diet/ restrictions

Past Developmental History

Age when you first suspected a delay or problem in development

Which of the problem best describes your child

Period of normal development followed by a loss in skills

Period of normal development followed by a plateau, stagnation or non progression of skills

Developmental delay from birth or early in life

Other

Age at Communication Milestones (List in months)

First Speech-Like sounds

First Time said “mama” / “dada”

First word besides “mama” and “dada”

First time child used words to refer to something specifically

First time child put words together in a phrase

Pointing

Age at Motor Milestones (List in months)

Rolling Over

Sitting Without Support

Crawling

Creeping/Crawling

Standing Independently

Walking Independently

Potty Trained: Urine

Potty Trained: Stool

If your child lost skills (regressed) please fill out the fields below

Speech

Age when regression occured

Duration of regression

Was regression abrupt or slow

Age at which skill was regained

Fine Motor Skills

Age when regression occured

Duration of regression

Was regression abrupt or slow

Age at which skill was regained

Coordination

Age when regression occured

Duration of regression

Was regression abrupt or slow

Age at which skill was regained

Social Interaction

Age when regression occured

Duration of regression

Was regression abrupt or slow

Age at which skill was regained

Pointing

Age when regression occured

Duration of regression

Was regression abrupt or slow

Age at which skill was regained

Eye Contact

Age when regression occured

Duration of regression

Was regression abrupt or slow

Age at which skill was regained

Multiple episodes of regression

Age when regression occured

Duration of regression

Was regression abrupt or slow

Age at which skill was regained

Was regression associated with any of the following factors?

Viral Illness

Duration

Treatment

Other Details

Seizure

Duration

Treatment

Other Details

Fever

Duration

Treatment

Other Details

Rash

Duration

Treatment

Other Details

Vaccine

Duration

Treatment

Other Details

Mitochondrial dysfunction

Duration

Treatment

Other Details

Past Medical History for Child

Allergic Disorders & Treatments

Please check all that apply and fill in as needed

Asthma

Allergies

Nasal Allergies

Eczema

Food Allergies

Asthma

When Diagnosed

Duration

Treatment

Allergies

When Diagnosed

Duration

Treatment

Nasal Allergies

When Diagnosed

Duration

Treatment

Eczema

When Diagnosed

Duration

Treatment

Food Allergies

When Diagnosed

Duration

Treatment

Neurological Disorders

Please check all that apply and fill in as needed

Microcephaly

Macrocephaly

Hypotonia (low muscle tone)

Hypertonia (increased tone)

Tremor

Ataxia (Unsteadiness)

Apraxia (Poor coordination)

Easy Fatiguability

Exercise Intolerance

Muscle disorder/myopathy

Chronic Headaches

Epilepsy

Febrile Seizures

Nystagmus

Migraines

Head injury/Traumatic Brain Injury

Cerebral Palsy

Tic Disorder

PANDAS/PANS

PITANDS

Tourettes

Landau-Kleffner Syndrome

Other

Microcephaly

When Diagnosed

Duration

Treatment

Macrocephaly

When Diagnosed

Duration

Treatment

Hypotonia (low muscle tone)

When Diagnosed

Duration

Treatment

Hypertonia (increased tone)

When Diagnosed

Duration

Treatment

Tremor

When Diagnosed

Duration

Treatment

Ataxia (Unsteadiness)

When Diagnosed

Duration

Treatment

Apraxia (Poor coordination)

When Diagnosed

Duration

Treatment

Easy Fatiguability

When Diagnosed

Duration

Treatment

Exercise Intolerance

When Diagnosed

Duration

Treatment

Muscle disorder/myopathy

When Diagnosed

Duration

Treatment

Chronic Headaches

When Diagnosed

Duration

Treatment

Epilepsy

When Diagnosed

Duration

Treatment

Febrile Seizures

When Diagnosed

Duration

Treatment

Nystagmus

When Diagnosed

Duration

Treatment

Migraines

When Diagnosed

Duration

Treatment

Head injury/Traumatic Brain Injury

When Diagnosed

Duration

Treatment

Cerebral Palsy

When Diagnosed

Duration

Treatment

Tic Disorder

When Diagnosed

Duration

Treatment

PANDAS/PANS

When Diagnosed

Duration

Treatment

PITANDS

When Diagnosed

Duration

Treatment

Tourettes

When Diagnosed

Duration

Treatment

Landau-Kleffner Syndrome

When Diagnosed

Duration

Treatment

Other

When Diagnosed

Duration

Treatment

Psychiatric Disorders & Treatments for Child

Please check all that apply and fill in as needed

Mood disorders (bipolar, etc)

Depression

Aggressive/self injurious behavior

Obsessive/compulsive

Anxiety Disorder

Eating/Body Disorder

Addiction

Sleep Disorders

Sensory Integration Disorder

Others

Mood disorders (bipolar, etc)

When Diagnosed

Duration

Treatment

Depression

When Diagnosed

Duration

Treatment

Aggressive/self injurious behavior

When Diagnosed

Duration

Treatment

Obsessive/compulsive

When Diagnosed

Duration

Treatment

Anxiety Disorder

When Diagnosed

Duration

Treatment

Eating/Body Disorder

When Diagnosed

Duration

Treatment

Addiction

When Diagnosed

Duration

Treatment

Sleep Disorders

When Diagnosed

Duration

Treatment

Sensory Integration Disorders

When Diagnosed

Duration

Treatment

Others

When Diagnosed

Duration

Treatment

Learning and Attention Disorders for Child

Please check all that apply and fill in as needed

ADD/ADHD

Learning Disability

Dysgraphia

Dyslexia

Dyscalculia

Other

ADD/ADHD

When Diagnosed

Duration

Treatment

Learning Disability

When Diagnosed

Duration

Treatment

Dysgraphia

When Diagnosed

Duration

Treatment

Dyslexia

When Diagnosed

Duration

Treatment

Dyscalculia

When Diagnosed

Duration

Treatment

Other

When Diagnosed

Duration

Treatment

Social Developmental Disorders for Child

Please check all that apply and fill in as needed

Pervasive Developmental Disorder (PDD)

Autism

Asperger syndrome

Hyperlexia

Other

Other social developmental disorders

(please list)

Age at diagnosis

Who made diagnosis

Developmental pediatrician

Pediatric neurologist

Neurologist

Psychiatrist

Psychologist

Other (please specify)

Who made diagnosis (other)

Behavioral and Educational Treatments for Child

Please check all that apply and fill in as needed

Resource room

Inclusion classes

Accommodations

Special education

Speech therapy

Physical therapy

Occupational therapy

Applied Behavioral Analysis (ABA)

Reading or writing assistance

Assistance in study skills

Assistance in mathematics

Assistance in social skills

Resource room