Social, Health, And Development History Form Page 2
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2Optional Tool
Has the student ever experienced any problems in the following areas?
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Walking difficulty
Temper tantrums
Underweight/ Overweight problem
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Unclear speech
Failure to thrive
Difficulties learning to ride a bike, skip, throw, or catch
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Eating problems
Excessive crying
Difficulties making friends with other children
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Sleep problems
Vision problems
Difficulties forming relationships with teachers
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Hearing problems
Separating from parents
Please indicate any illnesses the student has had:
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Measles
German Measles
Scarlet Fever
Diphtheria
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Mumps
Tuberculosis
Frequent colds
Loss of consciousness
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Seizures
Rheumatic Fever
Any heart condition
Gastrointestinal problems
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Anemia
Meningitis
Encephalitis
Fever above 104 degrees
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Asthma
Allergies
Verbal and motor tics
Other, please describe:
__________________________________________________________________________________________
Has the student ever been on any long term medication? Yes No If “yes”, when and what kind? ____________
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Is the student presently on any medications? Yes No If “yes”, what kind? _____________________________
Has the student ever had psychological counseling or therapy? Yes No If “yes”, when and why? ___________
__________________________________________________________________________________________
Has the student ever had a neurological exam? Yes No If “yes”, when and why? ________________________
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Has the student ever had a psychological or psychiatric exam? Yes No If “yes”, when and why? ___________
Has the student ever had any contact with the Mental Health Center, Department of Social Services, or the
Department of Juvenile Justice? Yes No If “yes”, when and why? ____________________________________
__________________________________________________________________________________________
IV.
Educational Background:
Please indicate whether the student exhibits any of the following behaviors:
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Has a short attention span
Has fears
Needs more help with school work than others his/her age
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Unhappy most of the time
Seems impulsive
Overreacts when faced with a problem
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Requires a lot of attention
Enjoys games
Enjoys activities such as reading, drawing, writing, etc.
Does the student appear to be concerned about his/her present difficulties? Yes No
Please indicate any of the following that the student has experienced in school:
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Skipped a grade
Disliked going to school
Had frequent absences from school
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Had behavior problems
Had emotional difficulties
Changed schools several times in school year
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Got poor grades
Had difficulty with Math
Has been evaluated for special education
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Been retained
Had difficulty with Reading
Had difficulty with written expression
Prior to this time, had anyone (physician, teacher, relative, etc.) ever been concerned about the student’s ability
to learn? Yes No If “yes”, please explain: ______________________________________________________
_________________________________________________________________________________________
What are the student’s strengths? ______________________________________________________________
Signature of person completing this form: ________________________________________________________
Relationship to the student: __________________________________ Date: ___________________________
Please return this form to: ____________________________________________________________________
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