Developmental /Social/Health History

Student Name______DOB______

Address______Phone #______

Person Completing______Relationship to student______

Date______

Thank you for taking the time to complete this form. Information is used to help determine how to best help your child. The more information you provide the more accurate our information will be. Feel free to write additional information beside the question or on another paper. If you have any questions, please feel free to contact your child’s teacher or guidance counselor.

Please CIRCLE the word that best answers the question.

Family/Social History
Does the child live with his/her biological parent(s)? / Mother: Yes No ______
Father: Yes No ______
Other: Yes No ______
Has the child ever lived separately from biological parent(s)? / Yes No If yes, what age was the child and who was the caregiver?
Other people living in the home: / Name Age Male/Female Relationship to student
______
______
______
______
Do other adults play an important role in the child’s life? / Yes No If yes, name and relationship:
Primary Language Spoken in the Home: / English Spanish other:
Does any member of the child’s family (aunt, brother, parent, etc) have a history of the following? If so, please circle and/or explain. / Alcohol or drug abuse Anxiety Disorder Depression
Bi-Polar Disorder Learning/Reading problems Behavioral Difficulties Autism Attention Deficit Hyperactivity Disorder (ADHD)
Other:
Has your child experienced any of the following stressful events within the past 12 months? / Parents divorced or separated Child changed schools Parent changed or lost job
Family financial problems Custody change Family moved
Family accident or illness Homelessness Death in Family______
Other (Please describe):

School History and Current Concerns

Before kindergarten, did your child attend? / Preschool Day care Head Start
Has your child repeated a grade? / Yes No (if yes, indicate grade)______
Please circle which describes your child’s feelings about school in the elementary school grades (if applicable): / Likes school Eager
Dislikes school Fearful/Anxious
Please circle which describes your child’s feelings about school in the middle and/or high school grades (if applicable): / Likes school Motivated
Nervous Dislikes school
Language concerns: / Difficulty expressing ideas Articulation (does not speak clearly)
Difficulty understanding what they are being told Stuttering
Reading Skills: / Below Peers Average Above Peers
Concerns:
Math Skills: / Below Peers Average Above Peers
Concerns:
Writing Skills: / Below Peers Average Above Peers
Concerns:
Describe your child:
(circle those that apply) / Nervous / Impulsive / Shy / Helpful / Disorganized
Happy / Artistic / Intelligent / Athletic / Low Self Esteem
Emotional / Confident / Angry / Unfocused / Overactive
Do you have concerns about your child’s school progress (e.g. academic, social, behavioral) / Yes No (if yes, please describe.)
How do you feel your child can best be helped?
List activities your child enjoys (gymnastics, basketball, coloring, etc.):

Early Development

Was the child born full-term? / Yes No (If no, how many weeks was the pregnancy?)______
Complications / Falls Blackouts Emotional Stress Toxemia
Excessive Bleeding Lack of Prenatal Care Other:
Delivery / Induced Vaginal Unusually long labor (# hours_____)
Caesarian Breech Complications:______
Alcohol Consumption / Yes No (If yes, indicate frequency______)
Tobacco use / Yes No (If yes, indicate frequency______)
Other drugs used during the pregnancy: / Marijuana Cocaine Stimulants Pain Killers Methamphetamine Anti-Depressants Other: Frequency:
Newborn Concerns (lack of oxygen, incubator, etc): / Yes No if yes, explain:
Developmental Milestones / Sitting: Early (3–6 mos.) Average (7–12 mos.) Late (over 1 yr.)
Walking: Early (7–12 mos.) Average (12–18 mos.) Late (over 18 mos.)
Speaking: Early (9–17 mos.) Average (18–24 mos.) Late (over 2 yrs.)
Toileting: Early (1–2 yrs.) Average (2–3 yrs.) Late (over 3 yrs.)
*Age-range information from Centers for Disease Control and Prevention [CDC]
Has your child received any early intervention services (e.g. First Steps)? / Yes No if yes, which of the following?
Speech therapy Occupational therapy (OT) Physical Therapy (PT)
Developmental Intervention (DI) Other:

Health and Medical History

Hospitalizations / Yes No If yes, explain:______
Operations / Yes No If yes, explain:______
Chronic Illnesses (ear infections) / Yes No If yes, explain:______
Seizures/Convulsions / Yes No If yes, explain:______
Head Injuries / Yes No If yes, explain:______
Allergies / Yes No If yes, explain:______
CurrentMedications / Type Dosage Reason for use
______
______
______
______
Past prescribedmedications: / Types, reason for use, and dosage:
Describe the child’scurrent overall health: / Excellent Good Fair Poor
comments:
Have glasses or contacts been prescribed? / Yes No if yes, does your child wear them?
Does your child have hearing problems? / Yes No if yes, please describe:
Does your child wear a hearing aid? / Yes No
Does your child have any problems sleeping? / Yes No (if yes, specify by circling below)
Difficulty falling asleep Awakens during night Nightmares
Bedwetting Loud snoring Wakes too early
Sleep apnea
Average number of hours your child sleeps at night: ______
Medical/Psychological Treatment / Past: Yes No (Agency/Dr.______)
Present: Yes No (Agency/Dr.______)
Community Involvement (IMPACT, Social Services, etc.) / Yes No explain: