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DEVELOPMENTAL HISTORY QUESTIONNAIRE

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DEVELOPMENTAL HISTORY QUESTIONNAIRE All questions contained in this QUESTIONNAIRE are strictly confidential and will become part of your clinical record. DEMOGRAPHICS Client s Name: (Last, First): M F (mm/dd/yyyy): Name of Parents: Family Heritage: ( Canadian/Dutch/French) Marital Status: Single Partnered Married Separated Divorced Widowed Religious Beliefs: ( Catholic/Islam/Judaism) Family Doctor: REASON FOR REFERRAL Chief Complaint [These would be the current areas of concern].

DEVELOPMENTAL HISTORY QUESTIONNAIRE . ... Writing Difficulties Speech Difficulties Reading comprehension difficulties ... No Yes If yes, what was the supplement and was it effective . Adolescence (12-18 years) (Skip if child is currently younger - go to Family Section) ...

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