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 ChildIf 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 ______
Page -1-
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: ______
Page -2-
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:
______
______
______
______
November 2011 Page -3-