Iredell Statesville Schools SDH by ITj2V9

VIEWS: 2 PAGES: 3

									Iredell Statesville Schools
                                                      Iredell Statesville Schools
                                        SOCIAL/DEVELOPMENTAL HISTORY


Student Name: ________________________________________                          School: ___________________________________

Grade: _____          Date of Birth: _____________      Sex: M/F                Today’s date: _____________________________

Person completing this form: _____________________________                          Relationship to child: ______________________


FAMILY INFORMATION
Please list all people living in the household:

                                 Name                                                        Relationship to Child




If 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:

        Allergies                                   Ear Infections                         Motor tics
        Anxiety                                     Frequent headaches                     Muscle weakness
        Asthma                                      Frequent stomach aches                 Over/Underweight
        Attention problems                          Growth problems                        Paralysis
        Autism or Asperger’s Disorder               Heart problems                         Seizures
        Broken bone(s)                              High blood pressure                    Skin rashes
        Coordination problems                       High fevers                            Sleep problems
        Depression                                  Hyperactivity                          Speech problems
        Diabetes                                    Liver problems                         Thyroid 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              Lies                   Harms others               Harms self                Has temper tantrums
Cries easily        Runs away              Avoids schools             Seems angry               Difficulty concentrating
Seems anxious       Has mood swings        Appears withdrawn          Uses drugs or alcohol     Seems 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 member           Death /loss of a close friend               Separation/Divorce        Parent remarried
Health problems in student         Health problems in a family member          Sexual/Physical Abuse     School problems
Student moved to a new school      Student moved to a new home                 Trouble with the law      Removed 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-

								
To top