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 Initial
Health and Developmental History
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When
obtaining an initial health and developmental history,
ask the child’s family about:
Birth
History (for children 5 years and younger)
- Mother's
pregnancy
- Delivery
- Birthweight
- Neonatal
period
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Medical
History
- Illnesses,
infectious diseases, and chronic health conditions
- Injuries,
hospitalizations, or surgeries
- Visits to
other health professionals, facilities, or the emergency room
- Immunizations
- Metabolic
and other health screens
- Food and
drug allergies
- Eating habits
- Medications,
vitamins, and supplementary fluoride
Family
History
- Health of
significant family members
- A three-generation
family health and social history, including congenital disabilities
and genetic disorders
- Depression
or other mental health problems in the immediate or extended family
- Alcoholism
or other substance use (including tobacco)
in the immediate or extended family
- Family transitions
(birth, death, marriage, divorce, loss of income, move, incarceration)
- Plans for
future pregnancies or prevention of pregnancy
- Medical information
about the child if the child is adopted or in foster care
Social
History
- Race/ethnicity
- Primary language
spoken at home
- Household composition
- Parents' marital
status
- Occupation
of parents
- Child care
arrangements/Preschool
- School performance
- Peer relationships
Review
of Systems, as well as:
- Nutriton
- Elimination
- Sleep patterns
- Environment
Developmental
and Behavioral
History
- Fine and
gross motor coordination
- Social and
emotional development
- Cognitive
skills
- Speech and
language development
- Development
patterns (sleep,
eating, stressors, learning style, physical changes)
- Child’s
achievements
- Discipline
issues (tantrums, limit-setting, increasing
independence)
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