Developmental History Information Form (Page 2 of 2) in pdf

Is this child presently on any medications? Yes No

If “yes”, what kind?_________________________________________________________________________

Has your child ever had psychological counseling or therapy? Yes No

Complete the following if “Yes”: Counselor’s Name:____________________________ Phone:____________

Has this child ever had a neurological exam? Yes

No

If “Yes”, please specify:______________________________________________________________________

IV. Educational Background:

Did this child attend preschool? Yes No

If “Yes”, where and for how long?______________________________________________________________

Have any relatives had difficulties similar to those this child is experiencing? Yes No

If “Yes”, please explain: _____________________________________________________________________

Please indicate whether this child exhibits any of the following behavior:

Has a short attention span

 Has Fears

Overreacts when faced with a problem

Unhappy much of the time

Seems impulsive

Requires a lot of attention

Enjoys active games

Enjoys activities such as reading, drawing, writing, etc.

 Needs more help with school work than others his/her age

Other: ____________________________________________________________________________________

Pleas indicate any of the following that this student has experienced in school:

Skipped a grade

Disliked going to school

Had frequent absences from school

Behavior problems Emotional difficulties

Changed schools several times in one school year

Poor Grades

Difficulty with Math

Has been evaluated for special education

Been Retained

Difficulty with Reading

Difficulty with writing or spelling

Other:____________________________________________________________________________________

V. Social History:

How does your child spend his/her free time?_____________________________________________________

__________________________________________________________________________________________

How may close friends does your child have? 0-2

2-4

4 or more

Please indicate if your child is able to do the following [now or earlier in their development]:

Show good eye contact

engage in pretend play

Discuss a variety of interests

Initiate conversation

initiate play

Is able to adjust to changes in routine

I give permission for my child to be observed, as needed, by educational specialists (speech-language

pathologists, school psychologists, hearing specialist, etc.)

Signature of person completing this form:________________________________________________________

Relationship to the student:____________________________________________________________________

Please return this form to:_____________________________________________________________________

Revised 5/2010

Developmental History Information Form Page 2

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