Free early intervention template

Developmental case history form and format

A developmental case history form in plain language, with open questions and sample answers showing how families describe their child.

Open questions, no milestone checklists
Asks every carer's home language
Fill in online, download as PDF

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What's inside

About Your Child and Family
Your Concerns
Pregnancy and Birth (As Reported)
Health
Daily Routines
How Your Child Communicates and Plays
What You Have Noticed
School, Preschool, or Daycare

+ 3 more sections

Developmental Case History Form

Child's name		Date of birth
Completed by		Relationship to child
Date completed		Preferred language for appointments

About Your Child and Family

Who lives at home with your child?

Who looks after your child during the day?Parents, grandparents, other relatives, a helper, or a daycare. Include the times if it changes through the day.

Languages spoken at homeList each language and who speaks it with your child.

Your Concerns

What are you concerned about?

When did you or others first notice this?

Who suggested you come to us?

What would you most like help with?

Pregnancy and Birth (As Reported)

PregnancyAny illness, medicines, or hospital stays during pregnancy that you were told about.

BirthWhere your child was born, how, and anything the doctors told you at the time.

After birthAny stay in a special care or neonatal unit, feeding difficulties, or other concerns you were told about.

Health

Illnesses, hospital stays, or operations

Fits or seizures, allergies, and regular medicines

Hearing and visionAny tests done, the results you were given, and any concerns you have.

Doctors and specialists your child sees

Daily Routines

Routine	What Usually Happens	What Is Easy	What Is Hard
Sleep
Eating and drinking
Bath and toileting
Dressing
Play
Going out

How Your Child Communicates and Plays

How does your child let you know what they want?

How does your child show they understand you?

What does your child like to play with, and with whom?

How does your child move around and use their hands?

What You Have Noticed

Things your child has learned recently

Is there anything your child used to do and has stopped doing?If yes, describe what and roughly when, as best you remember.

What upsets your child, and what helps them calm down?

School, Preschool, or Daycare

Where does your child go, and on which days and hours?

What have the teachers or carers said?

Previous Assessments and Therapy

Assessment or Therapy	Where and By Whom	When	What You Were Told / Report Available?

Family Strengths and Support

What is your child good at, and what does your family enjoy doing together?

Who supports your family, and is there anything else we should know?

Therapist Sign-off

Therapist	Designation	Registration	Date

How to fill it in

About Your Child and Family
Who lives at home, who cares for the child when, and each person's language.
More guidance
Ask who lives at home, who looks after the child at different times of day, and which language each person speaks with the child. These answers shape the rest of the work: who should be coached, which language goals use, and which routines are realistic to practise in. Accept the family's description of their household as they give it.
Your Concerns
What worries the family, when they noticed, who referred them, and what help they want.
More guidance
Put the concerns questions near the start so the family can say what brought them before answering pages of history. Ask when they first noticed, who suggested they come, and what they most want help with. Keep their words on the form; the team can translate concerns into clinical terms in the report.
Pregnancy and Birth (As Reported)
Short, neutral questions about pregnancy and birth, recorded as the family reports them.
More guidance
Keep these questions short and neutral, and make it clear that 'I don't know' is an acceptable answer. Ask the family to bring discharge papers or reports if they have them. Record what the family was told in their words, and do not ask them to interpret medical terms.
Health
Illnesses, hospital stays, seizures, allergies, medicines, hearing and vision checks, and doctors seen.
More guidance
Ask about illnesses, hospital stays, operations, seizures, allergies, and regular medicines, and about any hearing or vision tests with the results the family was given. List the doctors and specialists the child sees. Make sure the hearing question gets a clear answer, because the team will want to know whether hearing has been checked and when.
Daily Routines
For each routine: what usually happens, what is easy, and what is hard.
More guidance
For each routine, ask what usually happens, what is easy, and what is hard. The answers show where the family's day has friction and where goals can be practised later. Encourage short, concrete answers, and accept honest ones such as 'eats only when the phone is on' without comment on the form.
How Your Child Communicates and Plays
Open questions on how the child asks, understands, plays, moves, and uses their hands.
More guidance
Ask how the child lets the family know what they want, how they show they understand, what they like to play with, and how they move about and use their hands. Each question is open on purpose. The family's description becomes the starting point the team then checks in its own observations.
What You Have Noticed
Recent new skills, anything the child has stopped doing, and what upsets or calms them.
More guidance
Ask about things the child has learned recently, anything the child used to do and has stopped doing, and what upsets and calms them. If the family reports a skill that has stopped, pass it to the assessing clinician promptly and record the family's own account of what happened and roughly when.
School, Preschool, or Daycare
Where the child goes, when, what teachers say, and permission to contact them.
More guidance
Ask where the child goes, on which days and for how long, and what the teachers or carers have said. Ask the family's permission before the team contacts the setting, and note the answer on the form so nobody calls the school without it.
Previous Assessments and Therapy
Every earlier assessment or therapy: where, by whom, when, and what the family was told.
More guidance
List every earlier assessment or therapy: where, by whom, when, and what the family was told. Ask for copies of reports. If the family was given a condition name, write it down as reported and attach the report. The intake form records it, and the assessing team reviews the report itself.
Family Strengths and Support
What the child is good at, what the family enjoys, and who supports them.
More guidance
Close with what the child is good at, what the family enjoys together, and who supports them. Ending here leaves the family on a positive note after many questions about difficulties, and gives the team strengths to build goals around.

Developmental case history form and format: filled sample

Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.

About Your Child and Family

Lives with parents, paternal grandparents, and an uncle's family. Grandmother looks after V. in the mornings and a helper in the afternoons. Grandparents speak Gujarati with him, parents use Gujarati and English, and the helper speaks Hindi.

Your Concerns

'She does not turn when we call her name, but she hears the TV advertisement from the other room.' First mentioned by her playschool teacher in December.

Pregnancy and Birth (As Reported)

Mother was told she had high blood pressure in the last month. Born by caesarean. Stayed in the special care unit for five days 'for jaundice and feeding'. Discharge papers available.

Health

Ear infections 'many times' last winter. Hearing test at a hospital in 2025; parents were told it was fine but do not have the report. Sees Dr M., paediatrician, for routine check-ups.

Daily Routines

Sleep: sleeps with parents and wakes twice a night. Easy: falls asleep quickly after a story. Hard: wakes at 4 am and does not settle again.

How Your Child Communicates and Plays

'Takes my hand and puts it on what she wants. Understands 'come, let's go out' and goes to the door. Likes spinning the wheels of toy cars and climbing on the sofa.'

What You Have Noticed

'Used to say ta-ta and wave when his father left for work. Stopped a few months ago.' Calms when held tightly or when someone sings to him.

School, Preschool, or Daycare

Attends a playschool near home five mornings a week. Teacher says he plays on his own and cries at circle time. Family happy for the centre to call the teacher.

Previous Assessments and Therapy

Speech therapy at a hospital, weekly for three months in 2025; stopped when the family moved. Report available.

Family Strengths and Support

Very good at puzzles. The family goes to the beach every Sunday. His aunt lives nearby and helps on weekdays.

Case history form vs developmental milestone checklist

	Developmental case history form	Milestone checklist
What it asks	Open questions about the child, health, family, and concerns	Yes or no items about skills listed by age
How families experience it	Asked to describe their child	May read each item as a pass or fail
What the team gets	Context for the assessment, in the family's words	A set of ticks that still needs interpreting
Who interprets the answers	The assessing team, in the report	Often the family, at home, without support
Main use	Intake and history taking	Screening programmes that come with their own guidance

Tips and mistakes to avoid

Do

Offer the form in the family's language, or fill it in together at the first visit.
Ask the main daytime carer to contribute, since in joint families the grandmother may know routines best.
Send it a few days early so the family can find reports, birth papers, and the vaccination card.
Refer to the completed form in the assessment report instead of copying it out in full.

Avoid

Adding 'at what age did your child...' questions, which invite comparisons the form cannot support.
Asking about pregnancy in a way that suggests blame.
Skipping the languages question, then planning goals in a language the child rarely hears.
Placing the concerns question after pages of history.

About this case history form

A developmental case history form collects the family's account of their child before the first assessment: concerns, pregnancy and birth as reported, health, daily routines, languages spoken at home, how the child communicates and plays, and earlier assessments. This free child case history format asks open questions only, with no milestone checklists, so families describe their child in their own words.

Before a child's first assessment
When a family self-refers, to book the right professionals
When a child transfers from another centre
At re-assessment, to update health and family details

Most child development centres take a case history before the first assessment, either sent home or filled in at the first visit. It gives the team the family's view early, and later feeds the assessment report.

This form asks open questions with no skill lists or ages attached, so parents do not feel marked against a checklist. It asks who looks after the child during the day and which language each carer speaks.

Questions

What is a child case history format?

The set of questions a centre asks a family before or at the first visit: concerns, birth and health, routines, languages, school, and earlier assessments. This free child case history format can be filled in online and downloaded as a PDF.

Is there a filled sample of this case history form?

Yes. Each section on this page shows a fictional sample answer, using initials only, written the way a family might describe their child. The form itself is blank, and interpreting the answers stays with the assessing clinician.

Why are there no milestone ages on this developmental history form?

Milestone ages turn a history into a comparison, and families often remember ages loosely. The form asks what the family has noticed in their own words. If the team needs a formal developmental tool, it uses that tool separately.

Should parents fill it in alone or with a therapist?

Either works. Some families prefer to complete it at home where they can check documents; others find it easier to answer aloud. Sending it home first and going through it together at the first visit gets both benefits.

Can I use this form for a speech therapy or OT case history?

It is written for early intervention teams, so it covers several areas. A single-discipline therapist can use it as it is or remove the sections they do not need before sending it.

What should we do if the family reports that their child has stopped doing something?

Write down what the family describes and roughly when, and pass it to the assessing clinician promptly. The form records the report, and the clinician decides what follow-up is needed.

Can we keep completed forms in healhab?

A centre can build this form as its own template in healhab's Template Studio, or upload a completed paper form to the child's private document repository. Each centre sets up its own templates and services.

More early intervention templates

Case history form formats for other therapies

Write every report inside your clinic system.

Keep these as your clinic's own templates, write from reviewed session notes, publish branded PDFs, and keep families updated.

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