Social, Health, and Developmental History
Family Information
Instructions: Please complete the questions on this form to the best of your knowledge. This information will enable the school personnel to consider out-of-school factors in determining your child’s educational needs. If there are any questions you do not wish to answer or feel uncomfortable answering, feel free to leave them blank. However, please include any information that you think will help us in understanding your child.
Person completing the form: ______
Relationship to the child :______
Child’s Name: ______DOB: _____ Gender: Male Female
Grade: _____ Medicaid: Yes No
Referred by: ______Reason for Referral: ______
______
Family Information
Mother/Guardian: ______
Father/Guardian: ______
Family Status: Single Married Separated Divorced Foster Parents
Group Home Other:______
Was your child adopted: Yes NoDate of adoption:______
Who has legal authority to make educational decisions for this child? ______
Persons living in the child’s home:
NameAge RelationshipOccupationLearning/Medical
To Child Problems
______
______
______
______
______
______
______
Immediate family members living outside of the child’s home:
NameAge RelationshipOccupationLearning/Medical
To Child Problems
______
______
______
______
Health and Developmental History
Was the mother under a doctor’s care during the pregnancy? Yes No
Were there complications during pregnancy? Yes No
(If yes, please note the complication and when it occurred below)
Abnormal weight gain______Influenza______
Anemia______Maternal Injury ______
Emotional problems______Measles______
Excessive swelling______Rh incompatibility ______
Excessive vomiting______Gestational Diabetes ______
German measles______Vaginal bleeding ______
High blood pressure/toxemia ______Other: ______
Check how frequently the child’s biological mother used the following items during pregnancy with the child:
Tobacco products Never Sometimes Often
Alcohol Never Sometimes Often
Prescription Drugs Never Sometimes Often
Over-the-counter drugs Never Sometimes Often
Other drugs Never Sometimes Often
Mother’s age at child’s birth:______
Delivery: Full Term (38 weeks or later) Pre-Term ____ weeks gestation
Vaginal Labor Induced
Forceps used C-Section
Reason for C-Section: ______
Were there any problems before, during, or immediately after birth: Yes (explain below) No
______
Did the child require any of the following:
Apnea MonitorHow long? ______
IncubatorHow long? ______
Bilirubin lightsHow long? ______
Supplemental oxygenHow long? ______
VentilatorHow long? ______
Transport to Children’s HospitalName of Hospital ______
Other: ______
Birth Weight: ___ pounds ___ ouncesLength of hospital stay (days): Mother ____ Child _____
Approximately what age did the following occur?
Sit up______Babble______Toilet trained
Crawl ______Speak 1st words______Days:______
Stand alone______Combine 2 words______Nights:_____
Walk alone ______Speak in sentences______
Describe any abnormalities in growth patterns:
______
How does your child usually communicate?:
Gestures Single Words Short Phrases Sentences
Describe any problems with feeding (sucking, swallowing, drooling, chewing):
______
Check the characteristics of your child’s temperament:
Activity Level LowAverage High
Attention Level LowAverage High
Ability to deal with change PoorGood Very Good
Response to new things (people, PoorGood Very Good
places)
Mood UnhappyAverage Very Happy
Medical History
Family Physician: ______Date of last exam: ______
Has the physician been contacted concerning any school problems? Yes No
If yes, what were the physician’s findings? ______
Hearing Vision Speech
Has your child experienced problems with: Y N Y N Y N
Was your child checked by a doctor in last 2 yrs? Y N Y N Y N
If you answered yes to any of these items, please explain:
______
Please list any medical conditions that the child or a family member has, or has had in the past, that may impact learning or behavior (e.g. chronic ear infections, ear tubes, head injury, illness, addiction):
______
Please list any medications that your child is currently taking or has been prescribed within the last 4 years.
Medication/DosageReason for Med.Date(s) taken Prescribing Doctor Adverse Effects?
______
______
______
______
______
Does your child have glasses? Yes (Circle: Distance or Close-Up) No
If yes, does your child wear their glasses? Yes No
Does your child have a hearing aid? Yes No
If yes, does your child wear the hearing aid? Yes No
Has your child had any surgeries or hospitalizations (other than birth)? If yes, please list them below.
Approximate date(s)Type of surgery/illnessHospital
______
______
______
______
______
Is your child allergic to anything? Yes:______No
Home and School Information
Please list any concerns you have with your child’s academics or behaviors (e.g. failing a subject, anger control, poor attention):
______
Check if your child has experienced any of the following events that may have affected their social, emotional, or physical growth. Include approximate dates if known.
Accident ______Marital problems ______
Abuse (circle)–Sexual – Emotional – Physical ______Move ______
Birth (other siblings) ______Parent job change ______
Change of guardian ______Remarriage ______
Death of family member______Separations ______
Divorce______Sibling Problem ______
Illness______
Other:______
Please explain any checked items:______
______
Does your child get along well with their peers? Yes No
Does your child have friends? Yes No
If yes, are their friendsYoungerSame Age Older
If living with one parent, does the child have contact with the other parent? Yes No
If yes, how often - Weekly, or more often 1-2x per month Few times per year Never
Has your child ever lived with anyone other than with whom he/she is currently living? Yes No
If yes, please explain:______
______
If primary caregivers work outside the home, who cares for this child when caregivers are gone?
______
How many hours per day is this child in a child-care setting? ______
Do you consider your child to be a behavior or discipline problem? Yes No
If yes, has this increased recently? Yes (if yes, when? ______) No
How often does your child follow your instructions?
Never Sometimes Most of the time Always
Check if your child has received any of the following services:
Speech/Language Therapy Physical Therapy Occupational Therapy
Title I Reading Intervention Other ______
What individuals or agencies have been involved with your child?
AgencyName/Location
Children’s Hospital______
Child Development Watch______
Child Mental Health Services______
Division of Family and Child Services______
JuvenileCenter______
Public Assistance______
Medicaid______
SSI______
Housing______
Food Stamps______
AFDC______
Other: ______
What are some of your child’s strengths?
______
What activities does the family do together (e.g. watch TV, go camping, play sports)?
______
Briefly discuss any other important information about your child (If you need additional space, please attach another piece of paper).
______
Form 202