Biopsychosocial Assessment Page 5
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10Was a Cesarean section performed? Yes ____ No ____ If yes, for what reason? __________________
Was the child premature? Yes ____ No ____ If so, by how many months? _______________________
What was the child’s birth weight? _________________________________________________________
Were there any birth defects or complications? Yes ____ No ____ If yes, please describe: _________
_____________________________________________________________________________________
Were there any feeding problems? Yes ____ No ____ If yes, please describe: ___________________
_____________________________________________________________________________________
Were there any sleeping problems? Yes ____ No ____ If yes, please describe: ___________________
_____________________________________________________________________________________
As an infant, was the child quiet? Yes ____ No ____
As an infant, did the child like to be held? Yes ____ No ____
Were there any special problems in the growth and development of the child during the first few years?
Yes ____ No ____ If yes, please describe: ________________________________________________
The following is a list of infant and preschool behaviors. Please indicate the age at which your child first demonstrated each
behavior. If you are not certain of the age but have some idea, write the age followed by a question mark. If you don’t
remember the age at which the behavior occurred, please write a question mark.
Behavior
Age
Behavior
Age
Showed response to parent
______
Put several words together
______
Rolled over
______
Dressed self
______
Sat alone
______
Became toilet trained
______
Crawled
______
Stayed dry at night
______
Walked alone
______
Fed self
______
Babbled
______
Rode tricycle
______
Spoke first word
______
CURRENT HEALTH INFORMATION:
Describe child’s health generally: Good Fair Poor Is the child sexually active? No Yes
List any health problems the child has had:___________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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