Biopsychosocial Assessment Page 4
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10Place a check next to any behavior or problem that your child currently exhibits.
Check
Check
______ Has special fears, habits, or mannerisms
______ Is impulsive
(describe) ________________________
______ Show daredevil behavior
______ Sucks thumb
______ Gives up easily
______ Is slow to learn
______ Wets bed
______ Other (describe): _________________
_______________________________________
_______________________________________
EDUCATIONAL HISTORY
School: ______________________________________________
Grade: __________________
Place a check next to any educational problem that your child currently exhibits:
Check
Check
______ Has difficulty with reading
______ Has difficulty with other subjects (please
______ Has difficulty with arithmetic
list) ____________________________________
______ Has difficulty with spelling
_______________________________________
______ Has difficulty with writing
______ Does not like school
Is your child in a special education class? Yes ______
No ______
If yes, what type of class? _______________________________________________________________
Has your child been held back in a grade? Yes ______
No ______
If yes, what grade and why? ______________________________________________________________
Has your child ever received special tutoring or therapy in school? Yes ______
No ______
If yes, please describe: __________________________________________________________________
Has your child ever been suspended or expelled? Yes ______
No ______
If yes, please describe: __________________________________________________________________
DEVELOPMENTAL HISTORY
During pregnancy, was mother on medication? Yes ____
No ____ If yes, what kind? ______________
During pregnancy, did mother smoke? Yes ____ No ____ If yes, how many cigarettes each day? ____
During pregnancy, did mother drink alcoholic beverages? Yes ____ No ____ If yes, what did she drink?
_______________________________________________________________________________
Approximately how much alcohol was consumed each day? _____________________________________
During pregnancy, did mother use drugs? Yes ____ No ____ If yes, what kind? __________________
Were forceps used during delivery? Yes ____ No ____
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