DEVELOPMENTAL HISTORY

Name of Patient:
Date of Birth:
Date of Evaluation:
Chronologic Age:
Informant:
Developmental concern (s):
Domain

Domain
Skill Age Achieved Skill Age Achieved

Head Control (3 mons) Responded to sound (NB)

Prone (6 mons) Turned to sounds (6 mons)

Receptive Language
Sat alone (10 mons) Responded to name (9 mons)
Gross Motor

Stand with support (10 mons) Understand “no” (12mons)

Walked alone (18 mons) Command with gesture (15 mos)
Ran (2 1/2 yr) Command w/o gestures (2 yrs)
Up/down stairs (2 ½ yr) Pointed to BP (18 mons)
Pedal a trike (3 1/2 yr) Gave name and age (4 yrs)
Pedal a bike (7-8 yr) Knew address/birthday (6yr)
Fixated (NB) Vocalized (2 mons)
Reached (5 mons) Laughed/squealed (6 mons)
Fine Motor

Expressive
Language

Held bottle (7 mons) Babbled (8 mons)

Scribbled (2 yrs) Mama/dada (12 mons)
Unbutton/button (4 yr) Jargons (18 mons)
Copy figures (3-4 yr) 2-word phrases (2 yrs)
Smiled responsively (2 mons) Used Sentences (4 yrs)
Waved bye2/clapped (12 mos) Bedwetting
Personal/Social

Ate alone (3 yrs) Fecal soiling

Behavioral

Undressed (4 yrs) Tantrums

Toiled Trained (4 yrs) Head banging
Dressed alone (5 yrs) Aggression
Helped with chores (6 yrs) Hyperactivity
Ran errands (7yrs) Others

Overall Rate of Development: ______Normal ________Slow ___________Fast

Educational History
Age Level/Grade Regular/SPED Teacher: Pupil ratio Performance