Health and Developmental History
Initial Assessment
Informant: _________________________________________
Date: _________________________
Child’s Name: ____________________________________
Age: _____
DOB: ___________
Sex: _______
Address: __________________________
Home Phone: ________________ Work Phone: _______________
School: _______________________________________
Grade: _____
Teacher: _____________________
FAMILY HISTORY
Father’s Name: _______________________________
Occupation: _______________________________
Mother’s Name: _______________________________
Occupation: _______________________________
Who does the child currently live with: ____________________
Ages of sisters: _______ Brothers: _______
Other people living in home: __________________________________________________________________
Primary Language: _________________
Is home bilingual?
Yes
No
Language: _______________
Could this be a problem at school? _____________________________________________________________
What do you enjoy most about your child? _______________________________________________________
What concerns you most about your child? ______________________________________________________
Has any member of the family had a learning problem or mental retardation? (please explain):
Yes
No
__________________________________________________________________________________________
SCHOOL HISTORY
How do parents feel the child is doing at school? __________________________________________________
__________________________________________________________________________________________
What has the family already tried in dealing with this child? _________________________________________
__________________________________________________________________________________________
What does the family think should or could be tried? ______________________________________________
__________________________________________________________________________________________
When did the child learn to read? ___________________________
Write? ________________________
Has the child been retained?
Yes
No
Skipped a grade?
Yes
No
Grade: ______
Did the child have any preschool experience?
Yes
No Describe: __________________________________
Special programs that the child has participated in: ________________________________________________
FAMILY HEALTH HISTORY
Is there a history of the following in any blood relatives (mother, father, siblings, grandparents, aunts, uncles)?
Diabetes
Tuberculosis (TB)
Epilepsy/Seizures
Vision problems
Heart Disease
Hyperactivity
Asthma
Depression
Stroke
Cancer
Hearing Problems
Other___________