4 of 4

Social/Developmental History

I. Demographic Information:

Student’s Name (as it appears on birth certificate): / Address:
School: / Grade: / DOB:
Gender: / Ethnicity: / Phone Number:

II. Family:

Parent’s Name: / Stepparent’s name (if applicable): / Highest Grade Completed:
Parent’s Occupation: / Work Phone:
Parent’s Name: / Stepparent’s name (if applicable): / Highest Grade Completed:
Parent’s Occupation: / Work Phone:
Currently the student is
(please check): / □ Living with biological parents
□ A ward of the state
□ Other______/ □ Living with other relatives
□ Living with a foster family
Has the student always lived with his/her biological parents/guardian (circle): yes no
If no, please explain:
Are the parents separated or divorced (circle)? Yes No
Who has legal custody of the student? / How often does the student see the non-custodial parent/guardian?
If the student is not living with his/her biological parents, who has the legal authority to make any decisions regarding the student’s education?

Please list all family members and/or any other people living in the home: .

Name / Relationship / Age/Grade / How well do they get along?

Comments about student’s significant positive relationships and/or those of concern within the home: ______

Have any relatives had difficulties similar to those the student is experiencing? ____Yes ____No If yes, please explain: ______

Please describe any family history of medical problems, learning problems, attention problems, hyperactivity, mental illness, mental retardation, alcohol/drug use/abuse etc. ______

______

III. Medical History:

Did the mother receive prenatal care (circle)? Yes No / How long was pregnancy?
Please describe any complications that occurred during pregnancy which may have affected the student (i.e., toxemia, injury to the mother, mother illness, RH incompatibility, problems with baby, etc.):
Which of the following (if any) did the mother use while pregnant with the child (check all that apply)?
□ alcohol □ coffee/tea or caffeine □ cigarettes □ antibiotics □ illegal substances
□ other prescription medications/pills (list)______
□ other (list)______
How long was labor? / Apgar Score: / Child’s birth length: / Child’s birth weight: / Was the birth (please check):
□ Normal □ Cesarean
□ Breech □ Twins or more
Describe any complications with labor/delivery (i.e., cord wrapped around neck, blue baby, etc):
Describe any complications with the mother or child soon after delivery (i.e., breathing problems, jaundiced, etc.):
Length of Hospital Stay:
Mother: Child: / If child was in Neonatal Intensive Care (NIC) unit, how long was stay and which hospital?

Were all developmental milestones met at appropriate ages (circle one)? Yes No

At what age did this student first do the following? Please indicate month/year of age (if unsure/unknown, leave blank):

4 of 4

Social/Developmental History

Motor Milestones:

Turn over / Walk Alone
Sat Alone / Walk up/down stairs
Crawl

Language Milestones:

Showed Interest In/ Attraction to Sound / Spoke First Word
Babbled / Spoke Words in Combination
Any disappearance of language (circle)? Yes No
Age:______

4 of 4

Social/Developmental History

Does your student currently need assistance with any of the following:
□ Sitting / □ Standing / □ Walking / □ Stairs
□ Clothes Management / □ Toileting / □ Feeding

Does the student need/wear glasses/contact lenses? ____Yes ____No

Has the student experienced any problems in the following areas? (Check all that apply)
Diseases
□ Diabetes / □ Measles/Mumps/Rubella / □ Scarlet Fever / □ Tuberculosis
□ Meningitis / □ Rheumatic Fever / □ Diphtheria / □ Other:______
Illnesses
□ Skin rashes / □ Fever above 104 degrees / □ Frequent colds / □ Any heart condition
□ Anemia / □ Thyroid Problems / □ Liver problems / □ High blood pressure
□ Asthma / □ Dental problems / □ Hearing problems / □ Ear infections
□ Underweight/Overweight / □ Loss of consciousness / □ Frequent Nausea/Vomiting/Gastrointestinal problems
□ Other:______
Other
□ Unclear speech / □ Failure to thrive / □ Eating problems / □ Excessive crying
□ Severe depression / □ Difficulty separating from parents / □ Verbal and motor tics / □ Psychotic Disorders
□ Toileting accidents/Bedwetting / □ Other, please describe:
Has the student ever had a seizure (circle)? Yes No
If yes, please describe type, length, and frequency:
Please list any and all present and/or past allergies:
Please list any other precautions or adverse reactions:
Has the student had any inpatient and/or outpatient surgeries (circle)? Yes No
If yes, please describe and date:
Has the student ever been hospitalized or had any serious illnesses, accidents, or injuries including head injuries (and including any Emergency Room visits)? □ Yes □ No If yes, please explain:
Please describe any current diagnosed medical/health conditions:
Was the student ever exposed to any toxins (such as lead; circle)? Yes No
If yes, please explain:
Please list any long term medication(s) (past and/or present):
Medication and Dosage / For What Purpose / Approximate Duration of Usage
Evaluation History
(indicate “n/a” as necessary)
Evaluation / When / For What Purpose
Psychological/Psychiatric
Neurological
Physical Therapy
Occupational Therapy
Speech/Language Therapy
Other
Please describe any sleep problems the student experiences, if any (e.g., nightmares, too little sleep, too much sleep, sleepwalk, moves a lot while sleeping etc.):
Has the student ever had psychological counseling/therapy? □Yes □ No If yes, when and why?
Has the student ever had any contact with CAP, Mental Health, DSS, or Dept of Juvenile Justice (circle) Yes No
If yes, when and why?
If the student has an open case with any of these agencies, please list agencies and names and contact information about case managers and/or social workers:

IV. Educational Background:

Has the student ever repeated a grade (circle one)? Yes No If yes, which grade(s)?
How does the student feel about school?
What grade did these problems seem to begin? / List any suspensions and reasons why from the past year:
Please indicate any of the following that the student has experienced in school:
□ Skipped a grade □ Dislikes going to school □ Frequent absences from school
□ Changed schools several times in school year □ Poor grades
Does the student appear to be concerned about his/her present difficulties?

VI. Social Skills/Behavioral Background:

Within the past year, has the student done any of the following (check items that apply, circle if they are frequent problems):
□ Stole □ Had temper tantrums □ Set fires
□ Run away from home □ Harmed others □ Used illegal drugs or alcohol
□ Hurt animals □ Used a weapon in a fight □ Inappropriate sexual behavior
□ Had fights with others □ Lied □ Other
Has the student ever expressed a desire to purposefully hurt him/herself or others (please check)? □ Yes □ No
If yes, please explain:
Has the student ever purposefully hurt him/herself or others (please check)? □ Yes □ No
If yes, please explain:
Please check which discipline techniques you have tried with your child (check all that apply):
□ Verbal reprimands □ Rewards □ Time out (isolation) □ Physical punishment □ Removal of privileges □ Other ______
Which discipline techniques seem to work best and why?
Does the student have any regular chores or responsibilities? □ Yes □ No
If yes, how well does he/she do them?
Please indicate any of the following behaviors exhibited by the student:
□ Short attention span / □ Has fears / □ Unhappy most of time
□ Seems impulsive / □ Requires excessive attention / □ Enjoys games
□ Does not acquire learning skills at the same rate as other children his/her age
□ Other: / □ Overreacts when faced with a problem / □ Enjoys activities such as reading/writing/drawing

V. Social/Environmental Background:

Please check any of the following that may have affected the student and explain how each affected him/her.
□ Death of a family member or close friend □ Moves: Total number of times since birth: _____ total in the past year: _____
□ Health problems in family members □ Disruption by separation or divorce
□ Removed from home □ Sexual or physical abuse
□ Witnessed violence □ Experienced neglect
□ Birth of a brother or sister □ Academic problems
□ Homelessness □ Exposure to a disaster
□ Arrest or legal problems □ Victim of a crime
Notes:
Please explain any other events in the student’s life that may have resulted in lasting change in his/her behavior:

What skills would you like to see the student develop? ______

What are the student’s strengths? ______

In what situations is the student most successful? ______

What are the student’s best qualities and interests? ______

Parent Signature ______Date ______

*****If the student is LEP, make sure to complete the LEP Social Developmental History Attachment*****