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Maryborough Psychology & Health Clinic

Melinda Metaxas & Associates Pty Ltd

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Parent Form

Section B: Medical and Developmental History

Were there any complications or concerns during pregnancy with the child?

Were there any complications or concerns during, or immediately following the child's birth?

Were there any concerns regarding the child's early development? If so, please explain:

At what age did your child sit alone?

At what age did you child crawl?

At what age did your child walk alone?

At what age did your child babble?

At what age did your child speak first words?

At what age did your child speak in sentences?

At what age was your child toilet trained (day)?

At what age was your child toilet trained (night)?

Have any other services assisted with your child's development?

NoPaediatricianSpeech PathologistOccupational TherapistPhysiotherapistPsychologistEarly Intervention Services

What year or age were the services involved?

Has your child ever completed a speech or language assessment?

YesNo

If so, do you know the assessment date or results?

Has your child ever had a cognitive assessment (WPPSI, WISC)?

YesNo

If so, do you know the assessment date and results?

Has the child been previously diagnosed with any developmental disorders, or medical conditions?

Global Developmental DelayIntellectual DisabilitySevere Language DisorderAutism Spectrum DisorderADHDDown SyndromeCerebral PalsyGenetic disorderEpilepsyPhysical disabilityRecurrent ear infectionsMajor accidentMajor surgeryOther

Please provide details:

If relevant, what medication does your child take?

Has your child had a hearing test?

YesNo

If so, what was the date and results?

Has your child had a vision test?

YesNo

If so, what was the date and results?

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We are registered to provide services through:

Maryborough Psychology & ​Health Clinic​

Melinda Metaxas & Associates Pty Ltd

Maryborough Psychology & Health Clinic