Temperament & Social Development As a baby, was he/she easy to Yes No comfort or soothe? Did the baby have colic? Yes No Any trouble getting along with No Yes: other children his/her age? Does the child have any No Yes: difficulties getting or keeping friends? Explain if yes. The child gets along best with Same age Younger Older Adults (check all that apply): Does not hesitate to join in play with a group of children. Is sometimes hesitant to join in playing with other children, but does so when encouraged. Which of the following best Hardly ever plays with other children, but instead prefers to play by him/herself. describes the child in social interactions? Only interacts with family members. Does not typically seek out social interactions at all. Child/Family Medical History Date of last physical exam: Less than 6 months ago 6 – 12 months ago 1 – 2 yrs ago More than 2 yrs ago Any problems with vision or No Yes: hearing? Explain if yes. No Yes: Has the child ever had problems with recurrent ear infections? No Yes: Has the child had surgery to place tubes in ears? Give details if yes. None List incidents with dates: Has the child had any serious illness or injuries? Describe any head injuries (e.g., date, what happened, changes in behavior after the injury). None List hospitalizations with dates: List any hospitalizations or surgeries Has the child ever had: Seizures or epilepsy Tics/twitching Lead poisoning Loss of consciousness (check all that apply) Exposures to toxins Asthma Allergies What medications (if any) have been used to address these Medication: Dosage: How often: concerns in the past? Medication: Dosage: How often:
Temperament & Social Development As a baby, was he/she easy to comfort or soothe? Yes No Did the baby have colic? Yes No Any trouble getting along with other children his/her age? Does the child have any difficulties getting or keeping friends? Explain if yes. No Yes: No Yes: The child gets along best with (check all that apply): Same age Younger Older Adults Which of the following best describes the child in social interactions? Does not hesitate to join in play with a group of children. Is sometimes hesitant to join in playing with other children, but does so when encouraged. Hardly ever plays with other children, but instead prefers to play by him/herself. Only interacts with family members. Does not typically seek out social interactions at all. Child/Family Medical History Date of last physical exam: Less than 6 months ago 6 – 12 months ago 1 – 2 yrs ago More than 2 yrs ago Any problems with vision or hearing? Explain if yes. No Yes: Has the child ever had problems with recurrent ear infections? Has the child had surgery to place tubes in ears? Give details if yes. No Yes: No Yes: Has the child had any serious illness or injuries? None List incidents with dates: Describe any head injuries (e.g., date, what happened, changes in behavior after the injury). List any hospitalizations or surgeries None List hospitalizations with dates: Has the child ever had: (check all that apply) Seizures or epilepsy Tics/twitching Lead poisoning Loss of consciousness Exposures to toxins Asthma Allergies What medications (if any) have been used to address these concerns in the past? Medication: Dosage: How often: Medication: Dosage: How often:
6.6_social_developmental_history_form.docx