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