Parent Interview Form

PARENT INTERVIEW FORM

** The information submitted within this document is protected by the Privacy Act and will only be used for educational purposes.

Child’s Name: ______Birth date: ______

Parent’s Name: ______

Home Address: ______

Telephone: home: (____)-______cell: (____)-______

Child lives with: ____ Both Parents ____ Father Only ____ Mother Only ____ Guardian/ Other

Parents are: ____ Married ____ Remarried ____Separated ____ Divorced ____ Deceased

Mother employed: ____ No ____ Yes Where? ______Hours: ____ Phone: ______

Father employed: ____ No ____ Yes Where? ______Hours: _____ Phone: ______

List all other persons residing in the home including grandparents, cousins, half and step – siblings

NameSexBirthdateRelationship to child

10.

BIRTH DATA

Was the baby: ____ Full Term____ Premature____ Delayed

Delivery:____ Normal____ Instrument____ Cesarean

Weight at birth: ______Length at birth: ______

History of birth injury: ______

Mother was exposed to /contracted any infectious diseases during pregnancy?

____ No ____ YesSpecify: ______

Child was exposed to drugs, alcohol, and tobacco during pregnancy?

____ No ____ Yes Specify: ______

Mother was on medication during or just prior to pregnancy?

____ No ____ Yes Specify: ______

EARLY PERFORMANCE

Sat without support at what age in months: ______

Crawled at what age in months: ______

Walked alone at what age in months: ______

Spoke first word at what age in months: ______

Toilet trained at what age in months: ______

MEDICAL HISTORY

When did the child last visit a doctor? ______

Name of Doctor: ______

Child has been hospitalized: ____ No ____ Yes When? ______Why? ______

Child has had surgery: ____ No ____ Yes When? ______Why? ______

Child currently has health problems: ____ No ____ Yes

Explain: ______

Child is ____ Currently taking or ____ has taken medication.

Name of medication(s): ______

Dosage: ______

Purpose: ______

Side Effects: ______

Child wears glasses: ____ No ____ YesDate of last exam: ______

Child wears hearing aid: ____ No ____ Yes Date of last exam: ______

Record of accidents:

AccidentDateExaminerFindings

Child’s Doctor: ______Phone: ______

Does your child have any significant illness(s)? ______

Does your child have any allergies? ____ No ____ YesSpecify: ______

Has your child received any immunizations this year (include all please)? ____ No ____ Yes

If yes, give dates: ______

Please check and give date if your child has had any of the following illnesses:

Bronchitis ______Operations ______

Rheumatic Fever ______Convulsions ______

Diphtheria: ______Scarlet Fever ______

Ear Infections ______Measles ______

Rubella ______Whooping Cough ______

Pneumonia ______Tonsillitis ______

Chicken Pox ______Mumps ______

Strep Throat ______Others ______

SOCIAL HISTORY

My child would rather: (check appropriate blanks)

___ Play alone___ Play with many friends

___ Play with younger children___ Play with older children

___ Play with children of his/her own age

State your child’s reaction to:

Separations: ______

Frustration: ______

Punishment: ______

Darkness and Bedtime: ______

School, reading, learning: ______

Sharing: ______

Traumatic experiences: ______

Please share any behavioral or emotional concerns: ______

List 3 characteristics you find admirable in your child.

List any characteristics in your child’s behavior youfeel might make learning difficult for him / her.

Has your child been in trouble with juvenile authorities or police? ___ No ___ Yes

Explain: ______

Please list other schools your child has attended.

Name of School/ DistrictCity/StateDates of AttendanceGrades

EDUCATIONAL HISTORY

Has your child experience problems related to:

Grades: ______

Behavior: ______

Lack of participation: ______

Lack of friends: ______

Attention and Concentration: ______

What do you see as your child’s main concern? ______

______

What has been done in the past to help? ______

What are your expectations of this evaluation? ______

Signature: ______Date: ______