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Youth Medical & Developmental History Form

Youth History

Section 1: Family Information

Parents/Legal guardians:


What is the level of stress for each caregiver? (1 being not stressed at all and 5 being very stressed)

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Section 2: Infancy and Development History

Toilet Training


Age of toilet training:

After your child was fully trained, did he/she have any problems with:

Bed wetting:

Soiling problems:

Motor Development

Please bring any reports that you have to your first appointment.

Please bring any reports that you have to your first appointment.

Language Development

Please bring any reports that you have to your first appointment.

Early Intervention

Section 3: Pregnancy and Birth Information

Please select the answers that best describe any complications during your pregnancy with this child:



*Please bring birth records with you if you experienced any complications during pregnancy or birth of your child.

Section 4: Medical Information and History

Indicate whether the child has ever had any of the following



Has your child ever been assessed or treated by a...

*If yes, please bring any reports that you may have to the first appointment.



If this page is not applicable, simply advance to the next page.

Please list allĀ currentĀ medications your child is prescribed.

If you need more space, please bring a list of all medications to your first appointment.

Please list allĀ previousĀ medications your child has been prescribed.

If you need more space, please bring a list of all medications to your first appointment.

Section 5: School Information and History


*If "NO", you may simply disregard the following section and continue to the next page.

If yes, please bring a copy of the most recent IEP and/or 504 plan to your first appointment.

*If yes, please bring copies of any reports to your first appointment.

Section 6: Social History

Does your child have difficulty with the following:


Section 7: Family History

Please indicate if anyone in the biological family related to the child (e.g. parents, cousins, grandparents, siblings) has the following:


All done!

Press submit to complete the form.