Form 1a - Social And Developmental History
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2D-S-P CO-OP FORM 1A
Social & Developmental History
To be filled out by Parent
Revised: 6/08 Updated: 5/11
DUBOIS-SPENCER-PERRY EXCEPTIONAL CHILDREN’S CO-OP
TH
1520 ST. CHARLES STREET, SUITE 2
319 S. 5
STREET, ROOM 15
JASPER, IN 47546
ROCKPORT, IN 47635
PHONE: (812) 482-6661, FAX: (812) 482-9381
PHONE: (812) 649-9991, FAX: (812) 649-9997
SOCIAL AND DEVELOPMENTAL HISTORY
INSTRUCTIONS: Please complete this form to the best of your knowledge. This information will enable school personnel to determine your child’s educational
needs. If there are any questions you do not wish to answer or feel uncomfortable answering, leave blank. Thank you for your cooperation.
STUDENT FULL NAME
DATE OF BIRTH
CUSTODIAL PARENT NAME
ADDRESS
CITY _________________________________
ZIP
HOME PHONE
WORK PHONE
CELL. PHONE
NON-CUSTODIAL PARENT REQUIRING NOTIFICATION OF CONFERENCES:
NAME
ADDRESS
CITY
STATE
ZIP
NON-CUSTODIAL PARENT PHONE
WHAT SPECIFIC CONCERNS DO YOU HAVE REGARDING YOUR CHILD?
___ Behavior (Specify):______________________________________________________________________________________________________________
___ Academic Problems (Areas):_______________________________________________________________________________________________________
___ Attention (When? Where?)________________________________________________________________________________________________________
___ Medical (Problems)______________________________________________________________________________________________________________
HOUSEHOLD and FAMILY MEMBERS:
NAME
AGE
SEX
LIVES IN HOME?
FAMILY RELATIONSHIP
SCHOOL/BEHAVIORAL/HEALTH PROBLEMS
PREGNANCY/DELIVERY:
DURING PREGNANCY, DID THE MOTHER:
USE TOBACCO,
USE ALCOHOL,
USE PRESCRIPTION DRUGS
WHAT KIND OF MEDICATION DID MOTHER TAKE DURING PREGNANCY?_________________________________________________________________
LABOR COMPLICATIONS ___________________________________________________________________________________________________________
DELIVERY COMPLICATIONS ________________________________________________________________________________________________________
MEDICAL COMPLICATIONS DURING PREGNANCY ______________________________________________________________________________________
NEWBORN COMPLICATIONS:
WAS BABY BORN EARLY?(PREMATURE) _______________________________________________________________ BIRTHWEIGHT _________________
DID BABY HAVE ANY BIRTH COMPLICATIONS? ________________________________________________________________________________________
DID THE BABY GO HOME WITH YOU? ____________________ IF NOT, WHY ________________________________________________________________
DEVELOPMENTAL MILESTONES:
AT WHAT AGE DID YOUR CHILD DO THE FOLLOWING: SAT ______________________ CRAWLED ___________________ WALKED _________________
USED WORDS ___________________________ USED SENTENCES _______________________ TOILET TRAINED _______________________
DOES YOUR CHILD HAVE ANY PROBLEMS WITH: SPEECH? _______________ HEARING? ________________ VISION? ______________________
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