Iredell Statesville Schools

Iredell Statesville Schools

SOCIAL/DEVELOPMENTAL HISTORY

Student Name: ______School: ______

Grade: _____ Date of Birth: ______Sex: M/FToday’s date: ______

Person completing this form: ______Relationship to child: ______

FAMILY INFORMATION

Please list all people living in the household:

Name / Relationship to Child

If parents are separated or divorced: Date of separation: ______Who has legal custody? ______

DEVELOPMENTAL HISTORY

Did mother have any problems during pregnancy, labor & delivery? Yes/No (circle one)

If yes, please describe: ______

During pregnancy, did mother take any drugs or alcohol? Yes/No (circle one)

If yes, please describe: ______

How long was the pregnancy? ______How much did the baby weigh? ______

Did the baby have any problems after birth? Yes/No (circle one)

If yes, please describe: ______

Indicate the approximate age at which the child met these developmental milestones:

Sat alone ______Crawled ______Walked alone ______Spoke in single words ______

Used words in combination ______Toilet trained ______

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HEALTH HISTORY

Please circle any problems the child has ever had. Put a check mark by current problems:

AllergiesEar InfectionsMotor tics

AnxietyFrequent headachesMuscle weakness

AsthmaFrequent stomach achesOver/Underweight

Attention problemsGrowth problemsParalysis

Autism or Asperger’s DisorderHeart problemsSeizures

Broken bone(s)High blood pressureSkin rashes

Coordination problemsHigh feversSleep problems

DepressionHyperactivitySpeech problems

Diabetes Liver problemsThyroid problems

Tourette’s Syndrome

Has the child ever been hospitalized? Yes/No (circle one)

If yes, when and for what reason: ______

Please list any medications the child currently takes: ______

______

Who is the child’s regular doctor or pediatrician? ______

Has your child had a medical evaluation within the past year? Yes/No (circle one)

Is there a family history of disabilities or learning problems? Yes/No (circle one)

If yes, please describe: ______

Information Related to Head Injuries

Has the child ever experienced a concussion or head injury? Yes/No (circle one)

If yes, then: please explain: ______

As a result of the head injury, did your child lose consciousness? Yes/No (circle one) How long? ______

As a result of the head injury, did your child experience any memory loss? Yes/No (circle one) How long? ______

EDUCATIONAL INFORMATION

Did the child attend preschool or daycare? Yes/No (circle one)

Has the child ever repeated a grade? Yes/No (circle one)

If yes, what grade(s): ______

How does the child feel about school? ______

What educational problems concern you most? ______

______

Has the child received any school suspensions? Yes/No (circle one)

If yes, please describe: ______

Has the child had any previous counseling or testing services? Yes/No (circle one)

If yes, please list test provider and dates: ______

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SOCIAL/BEHAVIOR SKILLS

Does the child have any difficulty getting along with other children? Yes/No (circle one)

If yes, please describe: ______

Does the child participate in any group activities like scouts, sports, or other clubs? Yes/No (circle one)

If yes, please describe: ______

Please circle any behavioral problems the child has ever had. Put a check mark beside current problems.

Steals LiesHarms othersHarms selfHas temper tantrums

Cries easily Runs awayAvoids schoolsSeems angryDifficulty concentrating

Seems anxious Has mood swingsAppears withdrawnUses drugs or alcoholSeems depressed

Has the child ever been involved with the law or Juvenile Court? Yes/No (circle one)

If yes, please describe: ______

Does the child have any problems obeying adults in the home? Yes/No (circle one)

If yes, please describe: ______

What are the child’s strengths? ______

______

What type of activities does the child like to doe when he/she has free time? ______

______

FAMILY STRESS SURVEY

Place a check next to any event your family or child has experience in the past:

Death of a family memberDeath /loss of a close friendSeparation/DivorceParent remarried

Health problems in studentHealth problems in a family memberSexual/Physical AbuseSchool problems

Student moved to a new schoolStudent moved to a new homeTrouble with the lawRemoved from home

Other significant stressors: ______

______

______

Please list any other concerns that you may have about your child/s educational progress at this time:

______

______

______

______

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