Social, Health, And Development History Form

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Social, Health, and Development History
I.
Demographic Information:
Student’s Name: _________________________________ Date of Birth: ___________________ Age: _______
Gender: _____________ School: _______________________________________ Race: __________________
Home Address: ______________________________________________ Home Phone: ___________________
City: _______________________________________ State: ___________________ Zip Code: ____________
What are the present concerns of the parent and/or teacher in regards to the student?: _____________________
__________________________________________________________________________________________
II.
Family:
Mother’s Name: _____________________________ Stepmother? Yes No Highest grade completed: _______
Mother’s Occupation: _____________________________ How long at present employer? ________________
Employer: _________________________________________Work Phone: ____________________________
Father’s Name: _____________________________ Stepfather? Yes No Highest grade completed: _______
Father’s Occupation: _____________________________ How long at present employer? ________________
Employer: _________________________________________Work Phone: ____________________________
Has the student always lived with his/her biological parents? Yes No If “no” please explain: _____________
__________________________________________________________________________________________
If the parents are separated or divorced, how often does the student see the other parent? __________________
If the student is not living with his/her biological parents, who has the legal authority to make any decisions
regarding the student’s education? ______________________________________________________________
Please list all brothers and sisters, and any other children or adults living with the family.
Name
Relationship
Age
Education Level
How does the student get along with: (check as appropriate)
Good
Fair
Poor
Comments
Father/ Stepfather
Mother/ Stepmother
Brothers/ Stepbrothers
Sisters/ Stepsisters
Other Children
Other Adults
Check the activities in which this student often participates with the family:
Movies
Meals
Church
Visits with relatives
Conversations
Games
Sports
Trips
Television
Other, please list: _______
Have any relatives had difficulties similar to those the student is experiencing? Yes No If “yes” please
explain: ___________________________________________________________________________________
III.
Medical History:
At which age did this student first do the following? Please indicate month/year of age.
Turn over
Stand alone
Spoke first words
Sat Alone
Walk Alone
Show interest in or attraction to sound
Crawl
Walk up/down stairs
Spoke in sentences
Has the student ever had any serious illnesses, accidents, or head injuries? Yes No If “yes” please explain: ___
__________________________________________________________________________________________
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