Heath, Family, Developmental, and Behavioral History Form

1

Parent Interview

Today’s Date: __/__/__ Filled out by: ______

Child’s Name: ______Child’s Birth date: ______

Person with Legal Custody of Student

1. Name: ______Relationship to Student: ______

Address: ______

Street City State Zip Code

Home Phone: ______Email:______ALT Phone: ______

1. Name: ______Relationship to Student: ______

Address: ______

Street City State Zip Code

Home Phone: ______Email:______ALT Phone: ______

Other Adults and Children Living in the Student’s home:

Full or Half Siblings (Not living in home):

Primary Languages spoken in the home: ______Of Student:______

Concerns About Child

What are your concerns about the child? ______

______

At what age did the referring concerns first emerge? ______

What are the child’s strengths? ______

______

What are the child’s extra-curricular activities or interests? ______

______

What would you like to see happen for the child? ______

______

Health History (Perinatal Factors)

1. General obstetric status (circle one): Optimal Adequate Poor

1. Maternal age at time of the pregnancy (list): ______

1. Paternal age at time of pregnancy (list): ______

1. Length of pregnancy (circle/list): Full Term Premature @ ______weeks

1. Was there threatened miscarriage (circle)? YES NO If YES describe below: ______

1. Maternal Illness during pregnancy (circle all that apply): Measles Mumps Rubella

Influenza Syphilis Herpes

HIV Cytomegalovirus

Other (please list): ______

______

______

1. Medical problems during the mother’s pregnancy with the child (e.g., bleeding, infections, high blood pressure, diabetes, convulsions, injuries, etc.) (circle): YES NO if YES please describe: ______

______

1. Did the mother take any medications during during the pregnancy? (please circle) YES NO if YES please describe ______

1. Did the mother smoke during pregnancy (please circle)? YES NO

1. Alcohol exposure during pregnancy (circle)? YES NO If YES answer below
2. How often did mother drink? Every day Once a week Rarely
3. How much did mother drink? Just a little One drink Several drinks
4. When during pregnancy did mother drink? 1st Trimester 2nd Trimester 3rd Trimester

1. Drug exposure during pregnancy (circle): YES NO If YES, respond below
2. What drugs were taken? Thalidomide Depakene Depakote Depacon Other (list): ______
3. When during pregnancy were drugs taken? 1st Trimester 2nd Trimester 3rd Trimester

1. Complications during delivery (circle)? YES NO If YES, respond below
2. What complications? Respiratory Distress

Meconium aspiration

OTHER: ______

______

1. Birth weight (list) _____lbs. ______oz.

Health History (Infancy and Childhood)

1. Please check the childhood infections/viruses this student has had and indicate what age.

1. Did the child have any problems during the newborn period? YES NO (If yes, please describe) ______

______

1. Child’s Medical Diagnoses/Medical Issues Tuberous sclerosis Fragile X syndrome Fetal alcohol syndrome Epilepsy  Lead poisoning Chronic ear infections Tube placement Immune dysfunction Thyroidproblems  Arthritis Rashes  Allergy history Gastrointestinal symptoms Hydrocephalus Cerebral palsy Intellectual DisabilityAutism Spectrum Disorder (ASD)Other (list):______

______

1. Does the child wear glasses or contacts? YES NO

1. Has the student been diagnosed with any learning, social, behavioral, or emotional disorders (e.g., Anxiety, ADHD, Autism Spectrum Disorder,Intellectual Disability, etc)? NO YES (If yes, please describe below & submit any relevant reports supporting diagnosis)

1. Does the child take any medication for behavioral or emotional problems (circle)? YES NO (If yes please describe below): Name of Medication Dose Purpose Doctor ______

1. Does the child take any medication now for any other purpose (circle)? YES NO (If yes, please describe below): Name of Medication Dose Purpose Doctor ______

1. Has the child experienced any accidents, operations, or repeated medical problems not yet listed (circle)? YES NO (If yes, please describe below): Type of Problem Age Treatment Doctor ______

Developmental History

1. Age major milestones were accomplished (list)?First word ______Sentences ______Stands alone ______First Steps ______Walks alone ______Bowel training ______

1. Developmental regression observed (circle)? YES NO (If YES, answer below)

1. Age regression observed (list): ______
2. Describe the regression (list): ______

Child’s Temperament

If yes, please describe

1. Is the child overactive (circle)? YES NO ______
2. Does the child have trouble paying attention? YES NO ______
3. Does the child have trouble staying with one activity? YES NO ______
4. Does the child go from happy to sad quickly without any little apparent cause? YES NO ______
5. Does the child get frustrated easily? YES NO ______
6. Does the child get upset by abrupt changes? YES NO ______
7. Are the child’s emotional responses unpredictable? YES NO ______
8. Does it take the child a long time to warm up to new situations or new people? YES NO ______
9. Check all that apply that describe the student as an infant, toddler, or preschooler:

   

Behavioral/Social History

1. Unusual sensory sensitivities (circle)? YES NO (If YES, please describe.)
2. Over sensitive to stimuli (list): ______
3. Unusually interested in stimuli (list): ______

1. Abnormal eating or sleeping habits (list): ______

1. Unusual fearfulness of harmless objects (list): ______

1. Lack of fear for real dangers (list): ______

1. Self injurious behaviors (list): ______

1. Has the child had any problems in the following areas? If yes, please explain.

1. Temper YES NO ______
2. Fighting YES NO ______
3. Moods YES NO ______
4. Relations with others YES NO ______
5. Other behaviors YES NO ______

Serious Emotional-Behavioral Concerns

If yes, please describe below:

Child’s School History

(If YES, please describe)

1. Has the child had learning problems? YES NO ______
2. Has the child had behavior problems in school? YES NO ______
3. Has the child had social problems in school? YES NO ______
4. Has the child ever been held back a grade? YES NO ______
5. Other school problems? YES NO ______
6. Please list all schools the child has attended along with the correspondinggrades, and note if the childreceived remedial school age services, such as Response to Instruction and Intervention (RTII) services, Instructional Support Team (IST) services, guidance or social work school-based services, special education services, etc. and note duration of services?

1. Has the child received Early Intervention (EI) and/or Birth to Three services or other special services? YES NO (if yes, please describe the services and years received). ______

1. Has the child received outside counseling services? YES NO (If yes, please describe the services and the duration of services)

______

Rate perceived effectiveness of counseling services

1….2….3….4….5….6….7….8….9….10

(poor) (very effective)

Family History

Has any relative of the child had any of the following problems?

1. Neurological disease (e.g., seizures, fits or (If YES, answer below) weaknesses, etc.) YES NO ______
2. Chronic disease (e.g., diabetes, stroke) YES NO ______
3. Mental Illness (e.g., schizophrenia, bipolar or manic-depressive disorder, depression, anxiety, nervous breakdown) YES NO ______
4. Intellectual Disability YES NO ______
5. Learning Problems YES NO ______
6. Behavior Problems YES NO ______
7. Autism Spectrum Disorder YES NO ______
8. Excessive use of Alcohol YES NO ______
9. Drug problems, drug addiction YES NO ______
10. Trouble with the law YES NO ______
11. Trouble holding a job YES NO ______
12. Suicidal behavior YES NO ______
13. Violent Behavior YES NO ______
14. Other Problems YES NO ______
15. Has anyone in the child’s family seen a psychologist, psychiatrist, or other mental health worker YES NO ______

Current Living Situation

Do any of the following problems apply to the child’s current living situation?

1. Marital or relationship problems between the child’s major caregivers YES NO ______
2. Problems with siblings or other persons living in the home YES NO ______
3. Problems with work situation YES NO ______
4. Problems with present living situation or neighborhood YES NO ______
5. Recent major changes or stresses in the child’s living situation or family YES NO ______
6. Violence in the home or neighborhood YES NO ______
7. Alcohol or drug problems in the home or neighborhood YES NO ______
8. Other problems YES NO ______

Please write down anything else you think we should know:

______