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