Dorset HealthCare :: Your Child’s Development History – details required ahead of your child’s assessment for developmental disorders

Name of child

Date of birth

Name of the person completing the form

Contact number of the person completing the form

Relationship to the child

Current concerns

What is your greatest concern for your child at present?

What does your child find most challenging at the moment?

Is your child able to access their learning and participate in school life?

Further Comments

Language development

Does your child have any difficulties with listening and concentrating?

Does your child have any difficulties interacting with other people?

Does your child have any difficulties understanding what people say or following instructions?

Does your child like to chat, listen to others and continue conversation?

Does your child have any difficulties putting sounds, words and sentences together to share information, ideas and wishes?

Does your child understand figures of speech, jokes or teasing?

Further comments

Education

Name of pre-school/school and teacher

If a pre-school age, how many sessions does your child attend? If school age, does your child attend school full time or reduced time-table?

Has the pre-school/school highlighted any concerns to you regarding your child's speech, language, communication skills and interactions with staff or peers?

Further comments

Birth history

Were there any complications during the pregnancy?

Were there any complications during the birth?

Further comments

Milestones and early development

Did you experience any difficulties moving from liquid feeding to solid foods with your child? Does your child have any difficulties with eating or feeding, drinking or swallowing now?

Did you have any concerns about your child's development, for example do you find they are sometimes clumsy or they struggle to pick up objects? Has this persisted e.g. can they ride a bike?

When your child was a baby, did they babble a lot?

When your child was a baby, were they particularly quiet?

How old was your child when they said their first words? The word doesn't have to be said correctly, just that you knew what your child was saying.

Did your child achieve their other developmental milestones (sitting up, crawling, walking, toilet training) within the expected range?

What language is spoken at home?

What is your child's ethnic origin?

Further comments

Medical history

Has your child had speech and language therapy in the past?

Has your child had any infections / prescribed medication / hospital visits?

Do you have any concerns about your child's hearing or vision at the moment?

Does your child have any other diagnoses?

Further comments

Family history

Who lives at home?

Any family history of speech and language or communication difficulties?

Any family history of ASD or ADHD?

Any significant events affecting your child or family?

Are there any other services or professionals such as Social Care or Health Visitors working with you and your child?

Further comments

Socialisation / play

What does your child enjoy doing at home and how do they spend most of their time? e.g. what play activities do they like, do they like to read, computers, draw - please describe

Does your child have any particular hobbies or interests?

Thinking about early play - does/did your child enjoy interacting with others and taking turns, play imaginative, play independently? What was their favourite toy or object to play with?

Does your child interact with their peers at school/pre-school?

Does your child see friends outside of school (at home or at friend's house)? Do they enjoy parties or after school clubs?

Does your child interact well with siblings and share interest and activities

Further comments

Non-verbal communication

What are your observations about any of your child's non-verbal skills listed below

Pointing - does your child point to what they want, to give you extra clues? Also, do they look in the right place when you point at something?

Facial expression - does your child use a variety of facial expressions and are they able to understand others facial expressions?

Gesture - can your child interpret and understand others' gestures, mannerisms?

Eye contact - does your child make eye contact with most people they meet?

Mannerisms/tics

Further comments

Daily life

Does your child prefer a routine or are they flexible about the days schedule?

If planned events are changed, how does your child react?

How does your child manage change from one activity to another?

Further comments