Developmental Detail History- BR

**Present People:** [Insert names, roles, and relationship of all individuals present during the assessment] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Age:** [Insert patient age in digits] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Parental Concerns and Age of Onset:** 1. [Insert concern and age of onset in digits] 2. [Insert concern and age of onset in digits] 3. [Insert concern and age of onset in digits] 4. [Insert concern and age of onset in digits] (Continue the above format for each additional concern. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Previous Diagnosis / Assessments / Involved Agencies:** [Document any prior diagnoses, assessments conducted, and agencies or specialists involved in the child's care] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Family History:** [Insert details about parents and siblings including names, ages, education, occupations, consanguinity, and ethnicity] [Insert information on financial situation and availability of community support] [Document any family history of medical, developmental, or behavioural concerns] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Perinatal History:** [Insert details of the birth including gestation, delivery type, complications] [Document notable events in the newborn period, such as hospitalisation or feeding difficulties] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Medical History:** [Describe infancy behaviour and feeding history] [Document past and current medical concerns] [Insert current and past medications] [Insert known allergies] [Insert immunisation status] [Insert findings or concerns from hearing assessments] [Insert findings or concerns from vision assessments] [Insert findings or concerns from dental assessments] [Insert dietary habits, including restrictions, chewing issues, or ingestion of non-food items] [Insert sleep-related information including routines, duration, interruptions, snoring, or apnoea] (Write as a bulleted list. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **School:** [Describe school-based or other behavioural concerns] [Insert school name] [Insert class or year level] [Insert class teacher or guidance officer information] [Insert most recent school report findings] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Developmental History:** **Gross Motor:** [Insert details about milestones including age and whether achieved: rolling, crawling, sitting, pulling to stand, walking, running, climbing stairs, jumping, throwing, catching, pedalling etc.] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Fine Motor:** [Insert handedness, writing and drawing skills, grip types, use of scissors, threading, and ability to draw or copy figures like lines, circles, people etc.] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Self-help Skills:** [Insert details on drinking] [Insert details on feeding including utensils used] [Insert dressing/undressing skills including buttons, zips, shoes and socks] [Insert toileting ability including day/night control and level of independence] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Speech and Language:** **Expressive Language:** [Insert current level: babbles, single words, phrases, sentences – include examples] [Insert age in digits for first meaningful words] [Insert age in digits for 2–3 word spontaneous phrases] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Receptive Language:** [Insert understanding of basic and complex instructions, body parts, positions, conditional statements] [Insert estimated number of words understood and range of vocabulary] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Pre-verbal Communication:** [Insert use of gestures such as pointing, waving, clapping, nodding] [Insert information on using others' bodies to communicate (e.g. hand-over-hand, eye gaze, vocalisation)] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Articulation:** [Describe speech clarity to family members] [Describe speech clarity to unfamiliar adults] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Pragmatics of Vocalisations:** [Comment on reciprocal conversation vs monologue] [Comment on attention to voice, response to name, eye contact, orientation] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Other Aspects of Language:** [Document presence of echolalia, stereotyped utterances, neologisms, pronominal reversal, verbal rituals] [Comment on prosody – intonation, volume, rate, rhythm] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Social Skills:** [Comment on use of eye contact, social smiling, initiating interaction] [Comment on showing or directing attention, sharing, offering comfort] [Describe quality of social overtures including vocalisations and gestures] [Insert examples of social disinhibition or inappropriate social behaviours] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Play and Friendships:** [Describe solitary play – range and variability] [Insert interest in peers and responses to social approaches] [Comment on group play including initiator/joiner behaviour] [Describe nature of friendships, best friend concept, shared activities] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Interests and Behaviours:** [Insert any unusual or obsessive interests and their impact on the child or family] [Insert attachment to objects] [Describe repetitive behaviours such as flicking switches, opening/closing items] [Document compulsions, rituals, interest in object parts] [Describe rigid behaviours and response to change] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Unusual Sensory Interests:** [Insert any sensory-seeking or avoiding behaviours: smell, sound, touch, taste, visual, grooming activities] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Self-Stimulation and Mannerisms:** [Insert behaviours such as rocking, spinning, hand flapping] [Describe overall behaviour – tantrums, mood, aggression, anxiety, depressive symptoms] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Attentional Skills:** [Insert observations on attention, task completion, fidgeting, impulsivity, distractibility, forgetfulness, organisation] [Comment on whether attentional issues are task-dependent] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Behavioural Profile (on average):** [Insert observations across domains e.g., happy–sad, calm–anxious, quiet–busy, compliant–oppositional, truth–lies, gentle–rough, even–angry] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Anger Profile:** [Insert frequency, disruptiveness, destructiveness, violence, time to settle, coping strategies used] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Temperament:** [Insert any additional comments on temperament] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Physical Examination:** **Observations:** [Insert observations during free play, clinician-led tasks, and interaction with clinician and parents] [Note referencing, feedback seeking, distractibility, or inappropriate behaviours] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Growth Parameters:** [Insert weight in digits] [Insert height in digits] [Insert FOC in digits] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **Physical Features:** [Insert observations of dysmorphism] [Insert neurocutaneous findings] [Insert assessment of teeth, palate, hair] [Insert findings on ears and eyes] [Insert systemic examination findings] (Write as bullet points. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) **PLAN:** 1. [Insert first plan item] 2. [Insert second plan item] 3. [Insert third plan item] 4. [Insert fourth plan item] 5. [Insert fifth plan item] 6. [Insert sixth plan item] (Write as a numbered list. Only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference. If any information has not been explicitly mentioned, do not state that it was not mentioned; simply omit it. Always write any numbers, such as ages, measurements, durations, or appointment counts, in digits not in words. Use paragraph format, lists, or numbering depending on the structure of the information provided.)