CHILD DEVELOPMENT HISTORY MAP

Surname, name, age of the child _______________________________________________________________
Date of Birth _______________________________________________________________________
Mother: year of birth __________________________________________________________________
Education: ___________________________________, Occupation ________________________________
Are there harmful factors (which) ______________________________________________________________
Are there any other children, indicate gender and age _________________________________________________________
Father: year of birth _________________________________________________________________
Education: ___________________________________, Occupation ________________________________
Are there harmful factors (which) ______________________________________________________________
Does the child live with parents ____________________________________________________________
Parents divorced (indicate how old the child was at the time of divorce) _____________________
Lives with mother or father (specify) _________________________________________________________
The child is brought up in an orphanage ____________________________________________________________
Home conditions (how many family members) ____________________________________________________________
How many rooms_______ Does the child have a separate room _______________________________________
Disease in the family (also in the next of kin):
hearing impairment (for whom, from what age) ________________________, allergies _____________________,
epilepsy ______________________________, mental retardation ___________________________,
alcoholism _________________________________, rubella _________________________________,
venereal diseases _________________________, malformations _________________________,
speech disorders (which) _______________________, endocrine disorders ____________________
Are registered with a psychoneurologist or psychiatrist (children, mother, father, immediate family) _______
Who in the family is left-handed?
Pronounced abilities ______________________________________________________________
Has there been a history of suicide in the family?
Child’s diseases: colds – 4-6 times a year or more up to 3 years __________________________
at 3-7 __________________, after 7 ___________________, less than 4 times a year __________________
up to 3 years _____________________, in 3-7 years ______________________, after 7 years ____________________
Childhood infections (specify at what age): chickenpox _______________________________________________
measles ___________________, scarlet fever ____________, cow rubella ____ mumps (mumps)
meningoencephalitis __________________
other (specify) _________________________________________________________________________
State of vision _____________________________________________________________________________
Hearing condition (disease of ENT organs) __________________________________________________
Tonsils ___________________, adenoids ___________________, tonsillitis (how often) ________________
Tonsillitis (chronic tonsillitis) ____________________, Head injuries (at what age) _____________
Was ______________ treated in a hospital, with what diagnosis _____________________
Other diseases ________________________________________________________________________
Are there temperature rises for no reason ____________________________________________
Does BP change ______________________ Did the child have seizures (indicate age, how often,
under what circumstances) ________________________________________________________________________
It is registered at the dispensary (from what age, from which specialist, with what diagnosis) ___________
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The dream of the child ________________________, Characteristics of dreams _____________________,
Characteristics of the stool: is there constipation ___________________, or diarrhea ____________________,
cases of fecal incontinence ______________________________, Enuresis __________________________
Physical education group (basic, preparatory, dismissed) _______________________________________

prenatal development of the child
The child is wanted or not wanted _____________________________________________________________
Mother’s age during pregnancy _______________________, What kind of birth ___________________________
What kind of pregnancy is on the account ________________________, Number of abortions ______________________
How was the pregnancy: normal _____________________________________________________________
Nausea ___________________, vomiting ____________________, increased blood pressure _________________
ARI ______________________, mental trauma ______________, medication use _________________
fetal slaughter _________________, rubella ______________________, influenza ______________________
harmful factors _____________, smoking ________________, substance abuse ____________________
alcohol consumption _____________________, the possibility of conception while intoxicated _______________
*ARI – acute respiratory disease,
* ENT – from gr., laringo … – larynx, here … – ear, rhinitis-nose;
*BP – blood pressure.
What were the births (term, early, quick, protracted, delayed) __________________________
Birth weight ____________, applied (stimulation, extrusion, vacuum-
extraction, forceps, caesarean section, pedicle rotation) _____________________________________________
The child was born (term, premature, post-term) _______________________________
Did she scream right away or not ________________, Whether there were convulsions (for how long) ___________________________
Features at birth (asphyxia, birth trauma, hematoma, cord entanglement around the neck,
sciatic presentation, head) ____________________________________________________________

First year of life
Calm ________________________________, restless ________________________________
Breastfeeding months _______, frequent burping _______, since _______ months, sitting alone
Psychomotor development: holds head from _________ months, walks from _________ months, Follows eyes
moving objects from _________ months, grabs an object from ________ months, recognizes the mother from _______ months.
Speech development: voices from __________ months, first words from __________ months, phrases from ___________ months
General activity in the 1st year of life (mobile, interested, not interested, inhibited;
calm: likes to engage in toys himself; restless: requires constant adult attention) __
__________________________________________________________________________________ month
Has been manipulating objects since ______________ month, the game “Hide” etc. since ___________________ month.
Fright of the child (who) _______________________________________________________________ months.
What was sick in the 1st year of life __________________________________________________________
Does the child have: fatigue and weakness (what is the reason) _________________________________
Excessive sweating (when) ____________ There are dizziness (heads) _________________
There is a feeling of lack of air
Does the child experience abdominal pain _________, nausea _________, feeling bloated _________
Frequently complains of headaches
Are there any allergic reactions (if any, to what) ___________________________________________________
Is there a loss of consciousness _________, bedwetting (rare, sometimes, often) ____________
Experiencing anxiety, irritability, anger, aggressiveness, a sharp change in mood, tearfulness,
fear, intemperance, solitude (specify) ______________________________________________

Psychological and social status of the child
Psychological climate in the family _________________________________________________
Are there conflicts in the family?
Attitude towards the child in the family ____________________________________________________________
Goes to kindergarten (from what age) _________________________________________________
How did the adaptation go ________________________________________________________________
What is the relationship with the children in the group _______________________________________________________________
Have friends _____________________________________________________________________________
What does ___________________________________________________ do?
What are your favorite games ________________________________________________________________________
Features of the cognitive and emotional-volitional sphere _______________________________________
At what age did you start school?
Success ____________________________________________________________________________
What subjects do you like that cause difficulties ____________________________________________
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Attitude towards learning ________________________________________________________________
Relationships with classmates ____________________________________________________________
Relations with teachers ________________________________________________________________________________
Are there any conflicts (with whom, when) _____________________________________________________________
The attitude of parents to the child’s schoolwork _____________________________________________

Features of the personality of the child
Attitude towards oneself ________________________________________________________________________
Relationships with other people
Relationships with classmates _____________________________________________________________
Attitude to the case ________________________________________________________________________
Conclusions _____________________________________________________________________________
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