MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION CHILD/FAMILY HEALTH AND DEVELOPMENTAL ASSESSMENT
Current as of:
The completion of this form begins at initial contact with the family, but continues as information is collected throughout the life of the case. The worker may utilize a variety of sources to collect this information including parents or legal guardians, medical records or personnel or the resource provider. A copy of this form shall be given to the resource provider who is caring for the child. This form contains sensitive and confidential information regarding the child and his family and is protected by the “Health Insurance Portability and Accountability Act.” Neither the form nor its contents may be shared with any person not actively involved in the care and/or treatment of the child.
I. IDENTIFYING INFORMATION
Child’s name	DCN	DOB	Gender/preferred pronoun
Biological Parent #1 Name	DOB	Gender	Employer
Biological Parent #2 name	DOB	Gender	Employer
Has the child ever been adopted? Yes No	When	Where
Adoptive Parent #3 Name	DOB	Gender	Employer
Adoptive Parent #4 name	DOB	Gender	Employer
II. PRENATAL HISTORY (Biological /Mother’s history)
Age at time of Birth	Received Prenatal Care? Yes No	Medications/substance use during pregnancy
Any illnesses during pregnancy? (check all that apply)
Pre-eclampsia	Kidney/Bladder infection	RH incompatibility (RH-)
Gonorrhea	Chlamydia	German Measles
Syphilis	Diabetes	Hepatitis B C
HIV	High Blood Pressure/Toxemia	Any Other Illnesses (Explain Below)
Number of Pregnancies	Number of Live Births	Number of Miscarriages
III. BIRTH
Name and address of hospital where the child was born
Labor and delivery, any complications Yes No Infection Birth Defects	Weeks of gestation	Birth weight	Length	Apgar scores
Nursery Complications Yes No	Test Positive for drugs Yes No	Admitted to Neonatal Intensive Care Unit (NICU) Yes No
Did the child have any of the following within the first month of life? (Check any that apply)
Cyanosis/blueness	Jaundice/yellowness
Seizures	Infections
Bleeding
IV. NUTRITIONAL HISTORY
Any problems/difficulties with feeding? Yes No	Was the child breast fed? Yes No	Was the child fed formula? Yes No If so what type	Did the child gain weight properly? Yes No
V. DEVELOPMENTAL HISTORY
Did the child start doing things around the same age as other children? Yes No
Give the age at which the child did the following:
Smiled	Sat alone	Spoke single words	Walked alone
Fed self with spoon	Potty trained	Count to five	Spoke In 2 to 4 word Sentences
Did you question or have concerns about the child's development? Yes No
If yes, list below:

VI. EDUCATIONAL HISTORY
Name and address of current school	Current grade level	Average of grades
List all schools attended
Any problems at school? Yes No Academic Behavioral	Type of classes Regular Advanced Special Education	Does the child have an? IEP 504 Plan
List any behavior problems (list all concerns for school and home)
VII. FAMILY MEDICAL HISTORY
Does the biological mother/father/sister/brother/grandparents/aunts/uncles have any of the following?
Stroke	Hay fever/allergies	Anemia/sickle cell anemia/blood disorder
Asthma	Heart Attack	Emotional problems
Cancer	Diabetes	Birth defects
Tuberculosis	High Blood Pressure	Intellectual disability
Arthritis	Heart abnormalities	Learning Disorder
Epilepsy/Seizures	Blindness/vision loss	Retinal detachment
VIII. CHILD MEDICAL HISTORY
List all Doctors/Nurse Practitioners/Physician Assistants/Chiropractors/Doctors of Naturopathy
Name	Address	Specialty	Telephone number
Name	Address	Specialty	Telephone number
Name	Address	Specialty	Telephone number
Name	Address	Specialty	Telephone number
Are Immunizations current? Yes No	Adverse reactions to immunizations Yes No	List where Immunizations were given
Past medical history
Surgeries	Medical hospitalizations
Asthma	Any fractures/broken bones	Anemia/sickle cell anemia/blood disorder
Obesity	Lipid/Cholesterol problems	Urinary Tract Infections
Eczema	Recurrent ear infections	Constipation
Tuberculosis	Hearing loss	Vision concerns
History of cleft lip or palette	Other
Does the child… (check all that apply)
have siblings or playmates with lead poisoning?
live in or regularly visit a house or day care built before 1950?
reside in or visit a house built before 1978 with chipping paint or remodeling within the last six months?
mouth or eat non-food items (pica)?
play in bare soil or reside in a lead smelting area?
reside with an individual that works with or has hobbies using lead?
receive unusual medicines or folk remedies?
live in an area of the state at high-risk for lead poisoning? (list published annually)?
Is the child between 12 & 72 months and has never received a blood lead test?
IF THERE IS A CHECK IN ANY BOX, A BLOOD TEST SHOULD BE OBTAINED. Blood Test Obtained? Yes No Date:
IX. HIV/AIDS AND SEXUALLY TRANSMITTED DISEASES
Had any STDs? Yes No	Been exposed to HIV? Yes No	Has been tested for HIV? Yes No Test Results: Positive Negative
X. MEDICAL
Current medications Yes No
Medication	Dosage	Times per day	Route (mouth, nose)
Medication	Dosage	Times per day	Route (mouth, nose)
Medication	Dosage	Times per day	Route (mouth, nose)
Medication	Dosage	Times per day	Route (mouth, nose)
Medication	Dosage	Times per day	Route (mouth, nose)
Allergies/Medication allergies and adverse reactions
Current diagnosis/what treated for	Chronic/Ongoing Illnesses
Does your child drink alcohol? Last drink Yes No Last drink:	Does your child smoke? Yes No	Does your child use any recreational drugs? Yes No Last use or what drug:
XI. NUTRITIONAL HEALTH
Current Height	Current Weight	Have they recently lost or gain significant amount of weight
Any special diet Yes No	Food allergies Yes No	Feeding concerns (picky eater, texture sensitivities) Yes No
XII. PSYCHOLOGICAL/MENTAL HEALTH
Does your child receive counseling services? Yes No	Reason for counseling:
Name	Address	Specialty	Telephone number
Name	Address	Specialty	Telephone number
Has your child had psychological testing or evaluation? Yes	Type of test/evaluation:
Name	Address	Specialty	Telephone number
Name	Address	Specialty	Telephone number
Has your child ever been admitted to a psychiatric facility? Yes No
Facility Name	Address	Telephone number	Reason
Facility Name	Address	Telephone number	Reason
Has your child ever been in a residential treatment facility? Yes No
Facility Name	Address	Telephone number	Reason
Facility Name	Address	Telephone number	Reason
Has your child been seen by a psychiatrist? Yes No
Name	Address	Telephone number	Reason
Name	Address	Telephone number	Reason
XIII. DENTAL HEALTH
Last appointment completed	Any dental surgeries Yes No	Any issues to follow up Yes No
List all dentist from most current to past
Name	Address	Telephone number
Name	Address	Telephone number
XIV. OPTICAL/EYE HEALTH
Last appointment completed	Wears glasses/contacts Yes No	Eye concern (vision, cornea ulcerations, infections) Yes No	Any issues to follow up Yes No
List all eye care providers from most current to past
Name	Address	Telephone number
Name	Address	Telephone number
XV. Any other issues or information you think we need to know about your child
XV. Case Management
Case Manager Name
Resource Provider Name	Date Given