Fillable Form 1: Social and Developmental History

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Form 1: Social and Developmental History

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1
Social and Developmental History
Student’s Name: (Last, First, MI)______________________________________ Birth Date _____________ Grade ________
Address __________________________________________________________ Home phone _________________________
__________________________________________________________
Child is currently living with
(please select one)
:
Biological parent(s) Adoptive parent(s) Foster parent(s) Relative Other
If “Other”, please explain: ________________________________________________________________________________
Has the child ever lived with another person? YES NO
(If “yes”, please explain with whom, where, when, duration & circumstances):
If both biological or adoptive parents are not in the home, how often does the child have contact with him/her/them?
PARENT/GUARDIAN INFORMATION
Mother’s name _______________________________________________ Age _______ Occupation ___________________
Address
(if different from child’s)
_____________________________________________________________________________
Home phone
(if different from child’s)
________________________________ Business phone ___________________________
Health problems: (
Include history of diabetes, hypertension, heart disease, respiratory diseases, cancer, alcoholism, drug abuse, seizures, or mental illness)
Father’s name _______________________________________________ Age _______ Occupation ___________________
Address
(if different from child’s)
_____________________________________________________________________________
Home phone
(if different from child’s)
________________________________ Business phone ___________________________
Health problems: (
Include history of diabetes, hypertension, heart disease, respiratory diseases, cancer, alcoholism, drug abuse, seizures, or mental illness)
Marital status of parents:
Married YES NO
(If “no”, please elaborate below.)
How long? _____________
Widowed Year of spouse’s death __________ Years married? __________
• Separated How long? ____________
• Divorced How long? ____________
•
Remarried How long? ____________
(please elaborate below)
Stepmother’s name _____________________________________________ Age _______ Occupation __________________
Address
(if different from child’s)
_____________________________________________________________________________
Home phone
(if different from child’s)
________________________________ Business phone ___________________________
Health problems: (
Include history of diabetes, hypertension, heart disease, respiratory diseases, cancer, alcoholism, drug abuse, seizures, or mental illness)
Stepfather’s name _____________________________________________ Age _______ Occupation ___________________
Address
(if different from child’s)
_____________________________________________________________________________
Home phone
(if different from child’s)
________________________________ Business phone ___________________________
Health problems: (
Include history of diabetes, hypertension, heart disease, respiratory diseases, cancer, alcoholism, drug abuse, seizures, or mental illness)
2
Please list all siblings related to the child:
Name / Age Relation Residence Health/Learning Problems Grade
__________________________ ____________________ _________________ _______________________ _____
__________________________ ____________________ _________________ _______________________ _____
__________________________ ____________________ _________________ _______________________ _____
__________________________ ____________________ _________________ _______________________ _____
__________________________ ____________________ _________________ _______________________ _____
Are there any other people living in the household? ____________________________________________________________
Have there been any recent changes in the family structure?
(i.e. deaths, marriages, births, moves, traumas)
PRENATAL HISTORY
How long did the pregnancy last? __________________________________________________________________________
Medications taken during pregnancy (prescribed or over-the-counter
Please report whether any of the following occurred during the pregnancy and, if “yes”, explain.
YES NO When during pregnancy How much How often
Toxemia ___ ___ ____________________ n/a n/a
Alcohol ___ ___ ____________________ ____________ ____________
Drugs
(list type)
___ ___ ____________________ ____________ ____________
Type: __________________
Trauma ___ ___ ____________________ n/a n/a
Type
(i.e. fall, car accident, etc.)
: _____________________________________________________________________________
BIRTH HISTORY
Mother’s age at birth ____________ Type of delivery ____________ Birth trauma? _________________________________
Length of labor ________________ Anesthesia or medication used ______________________________________________
Birth weight __________________ Birth defects? ___________________________________________________________
Complications
(cyanosis, meconium, cord compression)
? ______________________________________________________________
How many days did infant stay in hospital? ___________
NEONATAL PERIOD & EARLY DEVELOPMENT
YES NO Treatment
Jaundice ___ ___ ____________________________________________
Convulsions ___ ___ ____________________________________________
Anoxia
(lack of oxygen)
___ ___ ____________________________________________
Use of life support systems ___ ___ ____________________________________________
Did the child gain weight consistently during the first year of life? YES NO
DEVELOPMENTAL HISTORY
Please record the age for the following:
Of first words ________________ Of first sentences ________________ Age sat alone ________________
Walked alone ________________ Toilet training started _____________ Toilet training completed ______
Did child crawl before walking? YES NO Was child well coordinated? YES NO
Problems with bedwetting? YES NO How long? _______________________ Intervention? ___________________
Repetitive habits
(i.e. thumbsucking, twirling of hair, rocking)
? ________________________________________________
Please describe child’s eating habits and attitudes
3
Has your child ever been (or is currently) diagnosed or treated for any of the following?
(Please provide copies of related reports.)
YES NO Age Treatment/Intervention
Attention Deficit Disorder ___ ___ ___ ___________________________________________________
Type: with Hyperactivity ___
with Inattentiveness ___
both ___
Bipolar Disorder
(Manic Depression)
___ ___ ___ ___________________________________________________
Depression ___ ___ ___ ___________________________________________________
Learning Disability ___ ___ ___ ___________________________________________________
Type: ______________________
Date of last assessment: _______
Emotional Disability ___ ___ ___ ___________________________________________________
Special Education services:
Occupational therapy (OT) ___ ___ ___
Physical therapy (PT) ___ ___ ___
Speech/language ___ ___ ___
Counseling ___ ___ ___
Other: _______________________ ___ ___________________________________________________
HEALTH ASSESSMENT
Height ____________ Weight ____________ Dental status? _______________________________________
How often does the child see the doctor? ________________________________________ Date of last visit: _____________
How often is the child absent from school? ______________________________________ General health status: __________
Frequent medications, including dosages and purposes:
Please indicate if your child has experienced any of the following:
YES NO AGE Treatment and/or Details of the situation
Vision problems ___ ___ ___ ___________________________________________________
Hearing problems ___ ___ ___ ___________________________________________________
Allergies ___ ___ ___ ___________________________________________________
Type:
Chronic illnesses ___ ___ ___ ___________________________________________________
Chronic conditions ___ ___ ___ ___________________________________________________
Concussion(s) ___ ___ ___ ___________________________________________________
Other serious head injury ___ ___ ___ ___________________________________________________
Fractures ___ ___ ___ ___________________________________________________
Stitches ___ ___ ___ ___________________________________________________
High fever ___ ___ ___ ___________________________________________________
Seizures ___ ___ ___ ___________________________________________________
Please list any hospitalizations this child has had, including reason, length of stay and age or year of hospitalization.
4
EDUCATIONAL HISTORY
Age when entered Kindergarten __________
Ever retained? YES NO If “yes”, in what grade(s)? ________________________________________________________
How many moves since the child entered school? _______________
Please list all school and locations of each that the child has attended.
School Location
(town/state)
Attended for what grades?
__________________________________ __________________________________________ __________________________
__________________________________ __________________________________________ __________________________
__________________________________ __________________________________________ __________________________
__________________________________ __________________________________________ __________________________
__________________________________ __________________________________________ __________________________
__________________________________ __________________________________________ __________________________
PARENT INPUT
Is your child’s school attendance consistent? YES NO
If “no”, please explain
Has this child’s educational experience been one that you have felt good about? YES NO
If “no”, please explain
Does your child get along with others, express feelings and take care of personal needs? YES NO
If “no”, please explain
Does your child process information like peers the same age in areas such as memory (short-term or long-term), reasoning and
attention? YES NO
If “no”, please explain
Does your child read, write and compute mathematics like peers the same age? YES NO
If “no”, please explain
Do you understand the reason for the current referral for testing? YES NO
If “no”, please contact the school psychologist as soon as possible.
What are your concerns regarding your child?
When was there an awareness or concern?
5
PERSONALITY
How would you describe your child’s activity level (under, over, average)? _________________________________________
Explain if and how the child displays the following:
Affection _______________________________________________________________________________________
Responsibility _______________________________________________________________________________________
Perfectionism _______________________________________________________________________________________
Anger _______________________________________________________________________________________
Impulsiveness _______________________________________________________________________________________
Sadness _______________________________________________________________________________________
Mood changes _______________________________________________________________________________________
Compulsion _______________________________________________________________________________________
Jealousy _______________________________________________________________________________________
Sloppiness _______________________________________________________________________________________
Aggression _______________________________________________________________________________________
Withdrawal _______________________________________________________________________________________
Frustration _______________________________________________________________________________________
Unusual fears _______________________________________________________________________________________
Anxiety _______________________________________________________________________________________
Suicidal threats
(if “yes”, how long ago?) __________________________________________________________________________________________
Suicidal attempts
(if “yes”, how long ago?) _________________________________________________________________________________________
Have you any concerns about the child’s sleeping patterns? YES NO
(if “yes”, please explain)
What is the child’s sleep schedule? _________________________________________________________________________
How well does the child accomplish tasks in work and play without your assistance?
Work:
Play:
Do you have concerns about the child in the areas of lying and/or stealing?
What ages are the child’s friends? __________________________________________________________________________
What kinds of activities do you share with the child?
What kinds of activities does your child seek out for him/herself?
6
What do you consider to be this child’s best qualities?
What frustrates you most about this child?
What kinds of things does this child say about him/herself?
Is there any other information that you feel would be helpful in understanding this child more fully?
Other remarks?
Information provided by: _____________________________________________ Relationship to child: _________________
Recorded by
(if other than person giving information)
: _______________________________________________________________
Title / relationship to person giving information: ______________________________________________________________
Date: ______________________ Translator used: YES NO
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Form 1: Social and Developmental History

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Completed 26 May 2021

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