Developmental History

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Which Sprout Therapist Should See this?
Please check all that apply to your pregnancy and prenatal exerience
Pregnancy

Difficulty getting pregnant or one or more miscarriages Complications during pregnancy Fertility drug use Flu or other infection Gestational diabetes
Please Check all that apply to your delivery
Prenatal

Age 35 or older Overweight or obese Autoimmune disease History of allergies and immune deficiencies, chronic fatigue, or fibromyalgia Thyroid dysfunction Possible exposure to toxic chemicals or pesticides
Please check all that apply to your experience
Birth

Breech presentation Cesarean section Forceps delivery Oxygen deprivation Bruising or swelling about the head and neck Induce labor
Was your child born premature? If so, how many weeks?
Has your child ever been diagnosed with Torticollis?
Does your child have seizures?
Does your child have a shunt?
Milestones
Please check milestones your child achieved during this time frame
If diagnosed with Torticollis, please specify which side
Birth to Age One

Colic and other digestive problems Alternate chronic constipation and diarrhea Spitting up (reflux) or projectile vomiting Pyloric stenosis (stomach obstruction) Allergies and/or Asthma Thrush (yeast infection) Eczema at birth that got worse Chronic ear infections that were aggressively treated with antibiotics Reactions to immunizations Sleep disturbances Hypotonia (low muscle tone) Possible sensory deprivation
By the end of the first month most babies:

make jerky quivering arm movements bring hands near face keep hands in tight fists move head side to side while laying on stomach focus on objects 8-12 inches away prefer human faces over other shapes prefer black and white or high contrast patterns hear very well recognize some sounds including parents voices
By the end of their third month most babies:

Raise head and chest when lying on stomach support upper body with arms when lying on stomach stretch legs out and kick when lying on stomach or back push down on legs when feet are placed on a firm surface open and shut hands bring hands to mouth grab and shake hand toys follow moving objects with eyes watch faces closely recognize familiar objects and people from a distance start using hands and eyes in coordination begin to babble and imitate some sounds smile at the sound of parents voices enjoy playing with other people may cry when playing stops
By the end of their seventh month most babies:

roll over both ways (stomach to back, back to stomach) sit up reach for object with hand transfer objects from one hand to the other support whole weight on legs when held upright develop full color vision and mature distant vision use voice to express jay and displeasure respond to own name babble chains of consonants (ba ba ba) distinguish emotion by tone of voice explore objects with hands and mouth struggle to get objects that are out of reach enjoy playing peek a boo show an interest in mirror images crawl
By Their First Birthday, Most Babies:

Sit without assistance Get into hands and knees position pull self up to stand walk holding on to furniture and possibly a few steps without support use pincer grasp with the thumb and forefinger say dada and mama use exclamations such as uh oh! try to imitate words respond to no and simple verbal requests use simple gestures such as shaking head no and waving bye bye explore objects in many ways (shaking, banging, throwing and dropping) begin to use objects correctly (drinking from a cup and brushing hair) find hidden objects easily look at correct picture when an image is named
Ages One to Two

Allergic symptoms: constant runny nose, red ears, puffy eyes White bumps on skin Increasing hyperactivity Strabismus (lazy eye), possibly nystagmus (involuntary shaking of the eyes side to side) Regression in milestones around age two
By Their Second Birthday, Most Children:

Walk on their own Pull toys behind them while walking Carry large toy or several toys while walking Begin to run Kick a ball Climb on and off furniture without help walk up and down stairs while holding on to support scribble with a crayon build tower of 4 blocks or more recognize names of familiar people, objects or body parts say several single words (by 15-18 months) use simple phrases (by 18-24 months) use 2-4 word sentences (want snack) follow simple instructions begin to sort objects by shape and color begin to play make believe imitate behavior of others show growing independence
Ages Two to Three

Delayed or abnormal crawling, or skipped stages of crawling before walking Clumsy or floppy movements To-in foot or knock-kneed Lisp in speech
Child's Diet

Increasingly limited diet due to strong likes and dislikes Preference for foods containing wheat and dairy Preference for milk and cereal or a bagel with cream cheese for breakfast Preference for grilled cheese sandwiches for lunch Preference for pizza pasta for dinner or secondarily chicken nuggets Snacks on raw carrots Loves eating French Fries
Does the Mother or Father Have any of the following Mental Health issues:

ADD/ADHD Anxiety Depression
Portions of this developmental history were taken from information presented in Disconnected Kids By Dr. Robert Melillo
Please Keep a two week journal of what your child eats for breakfast, lunch, supper and snacks. Please include drinks and how many ounces he/she drinks.

If your child has allergies or food intolerances, please indicate this in the journal. Evaluator will need this brought to the eval or scanned and emailed to her to include in the report.
Once you have completed this form and pressed the submit button, someone from our office will be in touch to set up the consultation appointment. The fee for this appointment is $250. This fee will be reimbursed if you participate in a Sprout Academy program.
With regards to your child's daily activites, please rate on a scale of 1-10 the occurence of these statements
Balance Concerns :

The vestibular system is all about balance and spatial awareness. Please rank the following statements on a scale of 1 to 10 (one indicates "does not apply" ten indicates "almost always applies").

Exhibits poor balance

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