FAMILY ASSESSMENTPART A: CHILD/YOUTH HISTORYChild/Youth Name
Assessment Date Parent/Guardian NameAssessment Location Client Home __________Edison _________Other __________
Current crisis with child/youth; history, duration, and possible precipitatingevents.
CHILD DEVELOPMENTAL MILESTONES:
Comment on prenatal and birth history; infancy issues suchas: toilet training, walking, talking and developmental delays/difficulties; any substance use/abuse at thetime of conception or during the pregnancy.
CHILD/YOUTH MEDICAL HISTORY:
Are childhood immunizations up to date?____Yes___NoDate and reason for most recent visit to physician:Has the child had an eye exam?___Yes___NoHas the child had a hearing exam? ___Yes___No Any known allergies?___Yes___NoIf yes, explain: Any known medication allergies? ___Yes ___NoIf yes, explain:
Indicate Child/Youth Medical History.Medical ProblemReference by NameTime FrameFrom – ToCurrent Status