Developmental History Information Form

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Developmental History Information
I. Student Information:
Student Name:_______________________________________________DOB: ____/____/____ Grade:______
Teacher:_____________________________________ School:_______________________________________
Parent(s)/ Guardian:_________________________________________________________________________
II. Family Information:
What are your child’s strengths?________________________________________________________________
__________________________________________________________________________________________
What concerns do you have for your child?_______________________________________________________
__________________________________________________________________________________________
In what language did your child first learn to talk?_________________________________________________
nd
If English is 2
language, how long has your child spoken English?___________________________________
What language is primarily spoken at home?______________________________________________________
Major Life Events Experienced by Your Child:
Divorce of Parents
Death of a Close Family Member
Major Illness
Home Dislocation
Home Fire
Natural Disaster
Is there any other major life event experienced by your child that you think may have had an impact on your
child?_____________________________________________________________________________________
III. Medical History:
Child’s physician________________________________ Physician phone #____________________________
Check any of the following complications that occurred during the pregnancy:
Toxemia
Gestational Diabetes
Measles
RH incompatibility
Alcohol
Tobacco
Low Oxygen
Premature Birth
Other___________________________________________________________________________________
Has this child ever had any serious illnesses, accidents, or head injuries? Yes
No
If “yes”, please explain:______________________________________________________________________
Has this child ever experienced problems in the following areas?
walking
temper tantrums
underweight/ overweight
unclear speech
failure to thrive
hearing
vision
sleep problems
eating problems
does not speak
fine motor skills (handwriting, tying shoes, etc)
Difficulty making friends
gross motor skills (running, riding bike, skip, etc)
Other
If any of the above are checked please specify:____________________________________________________
__________________________________________________________________________________________
Please indicate any illness this child has experienced:
Measles
Mumps
Asthma
Frequent Ear Infections
Gastro-intestinal problems
Diphtheria Seizures
Rheumatic fever
Loss of consciousness
Any heart condition
Meningitis Allergies
Verbal/ motor tics Other, please describe:___________________________
Revised 5/2010

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