Health and Developmental History


Please list all individuals residing in the patient's home.

Please list any additional siblings that do not live with patient.


FAMILY MEDICAL HISTORY

A) Is there a family history of the following? Please check all that apply.

1. Diabetes

2. Heart Disease

3. Seizures

4. Asthma

5. High Blood Pressure

6. Respiratory Problems

7. Blood Disorders

8. Cancer

9. Genetic Disorder

10. Hyperactivity

11. Impulsivity

12. Physical Abuse/Sexual Abuse

13. Emotional Abuse

14. Drug Addiction

15. Alcohol Problems

16. Emotional Problems

17. Mental Hospitalization

18. School Learning Problems

19. School Behavioral Problems

20. Speech/Language Problems

21. Special Education Services

B) Highest level of education completed by mother and father?


A) Prenatal

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