CHILD HISTORY

1. II attach PID label here - - Patient ID: Clinical Unit: - - - - Month Month Day Day Year Year 2 1 2 1 1 3 4 2 5 2 6 1 7 9 2 3 8 1 7 6 2 5 1 4 2 1 9 8 Biological mother Other relative Adoptive father Biological mother No Foster mother/father Adoptive mother Foster mother/father Grandmother/grandfather Stepfather Adoptive father Adoptive mother Stepmother Stepfather No Grandmother/grandfather Stepmother Other relative Biological father Female Yes Yes One Male Two Yes Biological father No Form Date: Coordinator Code: Visit: 1. What is the child's date of birth? 1 2. What is the child's gender? 3. What is your relationship to the child? 2 4. Who is the primary caregiver of the child? 5. Does the child live with the biological parent(s)? 5a. Number of biological parents living with the child: 5b. Did the child ever live with the biological parent(s)? months 5c. For how long: 6b. Hours per week they take care of the child: 6. Are there other people who take care of the child who do not live with the child? (Example: answer NO if an aunt lives with the parent and child and watches the child.) 6a. Relationship to child: ____________________________________________ CHILD HISTORY OPT Form 92 V1 (1-2) JAN 07

2. 8. Is this Visit 1? STOP 7. Has the child ever received or is currently receiving therapy? What kind? 1 1 1 2 3 1 1 3 2 2 2 1 2 4 2 1 2 3 1 2 1 1 1 1 2 1 2 3 1 1 2 3 1 Placid, happy Irritable and difficult to console Irritable, but easily consoled Don't know Don't know No Don't know Yes Don't know No Don't know Yes No Don't know Don't know No No Yes Don't know No Yes Yes Yes Don't know No Yes No No Yes Yes No Don't know Yes 7d. Educational therapy 7a. Occupational therapy 7c. Speech therapy 7b. Physical therapy 12. How best would you describe the infant's state from birth to 3 months? 13. Does the child sleep through the night? 13a. At what age did he/she start to sleep through the night? months 9b. [If still breast feeding at present time, fill in present age of child in months months 14. At what age did the child first roll over? months 18. At what age did the child first walk? months 15. At what age did the child first sit up? months 16. At what age did the child first crawl? months 10. Was your child cuddly as an infant? 11. Was your child colicky as an infant? 11a. At what age was the colic outgrown? months 17. At what age did the child first pull to a stand? months OBSTETRICS & PERIO THERAPY STUDY II 9. Has the child ever been breastfed? [Breastfeeding includes any suckling from the breast or feeding the child breastmilk for any duration, even once] 9a. At what age (in months) did the child stop breastfeeding? months [ If less than one month, fill in 00] [If can't remember at all, leave blank] - OR - OPT Form 92 V1 (2-2) JAN 07