Social Developmental History

Granville County Schools
Exceptional Children Program

Social and Developmental History
Students Name:
Date of Birth:
_______________________________
Teacher:
_________________________
________/_______/_______
School: ________________________ Grade: ____________
In order for us to better meet the educational needs of your child, please provide us with the following information concerning you
childs developmental, medical, and school history. Thank you.
Developmental History
During pregnancy with this student:
Was the child premature?
If so, by how many months/weeks? _________________________________________
Yes
No
Were there any complications for the child during delivery?

If yes, please explain_____________________________________________________
Yes
No
Were forceps used during delivery?

What was the childs birth weight? __________________________________________
Yes
No
Yes
No
Were there any sleeping problems?
Yes
No
Were there any special problems in the growth or development during the first few years?
(Sitting, crawling, walking, talking within normal ranges, behavior, activity level, attention)
If yes, please explain _____________________________________________________
Yes
No
With this child during infancy:

Were there any feeding problems?
Medical History
Please check next to any illness or condition that your child had or currently has. When you check an item, please note the age of the
child when it occurred.
Check Illness/Condition
Age
Head injury
_____
Allergies
_____
Types _____________________
Broken Bones
_____
Visual Problems
_____
Ear Problems
_____
Speech Problems
_____
Fainting Spells
_____
Loss of Consciousness _____
Concussion(s)
_____
Anemia
_____
Cancer
_____
Heart Problems
_____
Hepatitis/Jaundice
_____
Operations, list types:
_____
Other: _________________________________
Other: _________________________________
Check Illness/Condition
Age
Dizziness
_____
Headaches
_____
Convulsions
_____
Epilepsy
_____
Seizures
_____
Insomnia
_____
Bedwetting
_____
Extreme tiredness
_____
Bone/Joint Disease
_____
Meningitis
_____
Diabetes
_____
High Blood Pressure
_____
Bleeding Problems
_____
Overweight
Underweight
Hospitalization(s)-Reasons
Other: __________________________________
GCS006
Updated: July 2013
Family Dynamics
Is there any change in the number of siblings, family members or others in your home recently?
Yes
No
If yes, how many? _______ How is this affecting your child? ______________________________________________________
Medication Information
List all of the medications (prescription and over-the-counter) this student is currently taking and anything taken in the past year and the
reason they are/were taking it.
Current Medications
Reason
Past Medications
Reason Stopped
School History (School-Age Children Only)

Did the student attend pre-kindergarten, pre-school, day care, etc. prior to starting school?
Yes
No If, yes, where did they go? ___________________________________________________________________
Have there been any previous school problems in the following areas:
Areas
Type
When
Where
Academics
_________________________
______________________
____________________________
Behavior
_________________________
______________________
____________________________
Attendance
_________________________
______________________
____________________________
Please note any issues which you as a parent might have coped with as a child, or may currently be coping with as an adult, which
might affect your child. Also note anything else you think would be beneficial for us to know.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
______________________________________
Parent/Guardians Signature
___________________________
Date
GCS006
Updated: July 2013

Social Developmental History

Uploaded by

Copyright:

Available Formats

Social Developmental History

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Social Developmental History

Uploaded by

Copyright:

Available Formats

Granville County Schools

Exceptional Children Program

Were there any complications for the child during delivery?

Were forceps used during delivery?

Were there any sleeping problems?

With this child during infancy:

School History (School-Age Children Only)

You might also like