DEVELOPMENTAL PATHWAYS
SENSORIMOTOR HISTORY

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SECTION 1

Your Name    Your E-Mail address

Child's Name DOB Date

Please think of the various stages of your child's development, considering behavior which comes to your mind as you answer these questions. What do you think of as being different from other children you know? Were there times when his/her behavior was difficult to cope with in the family unit?

The following questions are posed to help in compiling a more complete picture of your child from early infancy to present developmental stage. Some of these questions may refer to children who are older than your own. Check the choice which applies: Yes, No, Used To, or N/A (not old enough yet, or for other reasons, nonapplicable.) Add narrative information which would also be important at the end of each section. Thank you for your cooperation.

MOTHER’S HEALTH DURING PREGNANCY, Did Mother:
1. Have any infections/illnesses during pregnancy? No Yes If yes describe
2. Have any shocks or unusual stress during pregnancy? No Yes  
3. Water break more than 24 hours before delivery ? No Yes When
4. Develop toxemia/high blood pressure? No Yes When
5. Have any complications during delivery and/or labor? No Yes  
6. Mother’s age at delivery
7. Number of Prev. miscarriages
8. If premature, how many weeks
9. Child's weight at birth
10. Child's weight at discharge
11. Apgar scores: 1 minute 5 minute
CHILD'S BIRTH, Was or did child:
1. Full term? No Yes  
2. Premature? No Yes  
3. Cesarean Section? No Yes  
4. Breech (feet first)? No Yes  
5. Face presentation? No Yes  
6. Transverse (sideways)? No Yes  
7. Have cord wrapped around neck? No Yes  
8. Require forceps? No Yes  
9. Have birth injuries? No Yes Describe
10. Require a fetal monitor No Yes  
11. Insufficient oxygen No Yes  
12. Cry right away No Yes  
13. Need intesive care Hospitalization? No Yes  
a. How long  
b. Prematurity No Yes  
c. Respiratiory problems No Yes  
d. Need respirator No Yes How long?
e. Small for gestat'l age No Yes  
f. Heart defect No Yes  
g. Need exch. transfusion No Yes  
h. Jaundiced No Yes How long under lights
i. Have congenital abnormalities No Yes  
j. Have seizures No Yes  
k. Have infection at birth No Yes  
l. Have surgery as a newborn No Yes  
m. Have feeding problems as a newborn No Yes  

Additional narrative information