Sample Outline of Child History Questionnaire
Basic identifying data:
- Child's name
- Date of birth
- Date of evaluation
- Person referring for evaluation
- Person filling out the questionnaire
- Child's behavioural problems for which being referred to
Referral information:
- Reason for referral
- Circumstances/factor judged responsible for this problem
- Child's strength
- Child's weakness
- Do parents agree about the nature and causes of the problem?
Family information:
- Address
- Telephone
- Parents (name, age, education, marital status)
- Child's natural, adopted, or fosters status
- Siblings (name, age)
- Other's living in home
- Approximate family income
- Father's occupation
- Mother's occupation
- Significant family or marital conflict
Pregnancy, birth history, neonatal period:
- Age of mother at delivery
- Health problems of mother during pregnancy
- Length of labour and any complications
- Delivery type (vaginal, Caesarean) and any complications
- Term length (full, premature, number of week's gestation)
- Birth weight and height
- Condition of baby (e.g., baby breathed spontaneously, Apgar scores)
- Type of nursery (e.g. normal new-born, paediatric intensive care)
- Days until discharge from the hospital after birth
- Medical problems after discharge (e.g., jaundice, fever)
- Any problems in the first few months