Developmental History and Family Home Questionnaire

Re- Evaluation

The following questions concern your child’s development and functioning within your family which may not be obviously relevant to your child’s school performance. The information and observations you provide give us a complete picture of your child and will be included as part of the comprehensive assessment. Thank you for your cooperation in completing this form.

Today’s date: ______

Child’s Name: ______D.O.B: ______

Person completing this form: ______Relationship to child: ______

Who has custody of the child: ______

Language spoken in the home: ______

Language spoken by the child: ______

Household members living with child:RelationshipAge

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Family/significant people outside the householdRelationshipAge

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Does anyone in the immediate family have a history of problems with:

Family / Student
Speech /  / Speech / 
Mental/Emotional /  / Mental/Emotional / 
Trouble with the law /  / Trouble with the law / 
Violence /  / Violence / 
Alcohol/Chemical dependency /  / Alcohol/Chemical dependency / 
Cognitive Delay /  / Cognitive Delay / 
Learning Problems /  / Learning Problems / 
School Problems /  / School Problems / 
Behavioral Problems /  / Behavioral Problems / 

Explain:______

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Does anyone in the immediate family have a history of problems with vision, hearing, unusual illnesses, ear infections, seizures, allergies, asthma, diabetes, dental, neurological issues? Explain: ______

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Does the child have a history of problems with vision, hearing, unusual illnesses, ear infections, seizures, allergies, asthma, diabetes, dental, neurological issues, head injuries, loss of consciousness, high fevers? Explain: ______

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Has your child ever received mental health or educational services (i.e. counseling, speech therapy, OT, PT..)

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Please comment on any additional medical information that you feel people working with your child should know.

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Many learning problems in childhood are temporary and may be brought on by changes in the life of a child and his or her family. Indicate which of the following events have occurred in your family. Check all that apply.

Event / Year / Description
 / Move to a new home
 / Change of school
 / Repetition of grade
 / Serious illness in family
 / Death in family
 / Divorce/separation of parents
 / Change in hours parent(s) are home
 / Loss of job
 / Parent began work out of home
 / Brother or sister left home
 / Marriage of brother or sister
 / New person joined family
 / Neighborhood concerns
 / Chemical or alcohol use
 / Homelessness
 / Foster home placement
 / Court placement
 / Involvement with the law
 / Family member in counseling
 / Other

Please indicate the following about your child by circling the most appropriate response:

General disposition/temperament: Easy-goingDifficultSlow to warm up

General activity level:LowAverageHigh

Response to changes in daily routine: Adapts wellSlightly agitatedBecomes upset

Please circle any behaviors and/or characteristics that describe your child:

Highly distractible / Wets bed / Very impulsive / Aggressive / Mature
Often noncompliant / Tantrums often / Difficult to calm / Manipulative / Perfectionist
Short attention span / Has few friends / Stubborn / Persistent / Often rocks
Prefers to play alone / Often angry / Often sad / Indifferent / Withdrawn
Has sleep problems / Cooperative / Affectionate / Cries often / Often fearful
Quick to anger / Moody / Insecure / Very restless / Suicidal
Hard to understand / Easily frustrated / Accident prone / Shy / Immature
Frequently interrupts / Happy / Eating problems / Boy/Girl crazy / Strange habits
Alcohol/drug use / Unusual interests

Comments: ______

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Please circle the following events that have occurred in your family and then describe:

Move to a new home / Change of school / Death in family / Divorce / Job loss
Repeated a grade / Separation / Homelessness / Marriage / New Job
Involvement with the law / Neighborhood concerns / Drug/alcohol abuse / Birth/new family member / Physical abuse
Sexual Abuse

Explain: ______

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What are your child’s current school problems? / When did you notice them? / What do you think caused them?

Do you feel your child’s school problems are the result of a cultural or other misunderstanding? If yes explain:

What are your child’s strengths and special abilities?

What does your child like to do?

Describe the way you’ve seen your child learn best.

How long does your child spend on homework each day?

Does your child complete homework independently, or does your child need your assistance?

What would you like to see happen for your child to help them be more successful?

Rate your child’s performance at home or in the community on the following items:

Does very well Sometimes Needs Always NeedsNot

Help Help Applicable

Follows 2-3 step directions (S)

Remembers (S)

Organizes well (O)

Uses planning skills (O)

Understands what he/she reads (A)

Understands what he/she sees (A)

Understands what he/she hears (A)

Learns a new game (A)

Recalls events from the school day (R)

Recalls specifics from special event (R)

Reads aloud (R)

Carries on a conversation (E)

Handwrites (E)

Problem solves (M)

Explains something he/she learns (M)

Assembles or repairs things (M)

Demonstrates artistic ability (M)

Knows basic math facts (R)

What other information should we know about your child? ______

Thank you for your input!

Revised 1/08- 1 -