Parent Questionnaire Social/Developmental History

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Parent Questionnaire
Social/Developmental History
Dear Parent:
Please help us to better understand your child. You may choose to supply part or all of the information requested.
This information is used for the purpose of identifying educational needs and will be maintained according to
Cabarrus County Schools Student Records Policy.
Student: School: Grade:
Form completed by: Relationship to student: Date:
I. Strengths and Concerns:

My child’s strengths are:
My child enjoys or likes:
My main concerns for my child are:
• Academic (describe):
• Behavioral (describe):
• Social or emotional (describe):
II. Medical and Developmental History:

Health of mother during pregnancy: Good Fair Poor (describe)
Mother’s age at child’s birth:
Child’s birth weight:
Birth History:
Long and hard labor Rapid delivery Head injury
Jaundice Premature Oxygen needed
Convulsions Breathing difficulty Other (explain)
Did your child have delays or problems with:

• Feeding/weaning No Yes (describe)
• Babbling No Yes (describe)
• Speaking first word No Yes (describe)
• Talking in phrases or short sentences No Yes (describe)
• Walking No Yes (describe)
• Toilet training (day) No Yes (describe)
• Toilet training (night) No Yes (describe)
Medical History:
Asthma/allergy Heart problems Seizures
Ear infections/tubes Headaches Sleep disturbances
Developmental delays High fevers Stomach aches
Frequent illnesses Hyperactivity Tics
Other (explain, e.g. surgery, speech or language problems, etc.)
Medications my child is taking:
Revised: January 2008 Social/Dev History

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III. School History:

Did your child attend: Private Home Daycare Preschool Head Start
Name of the preschool/daycare Child’s age Length of time child attended this preschool/daycare
Describe any specific difficulties:
Other schools your child has attended:

School name Child’s grade Length of time at this school
Describe any specific difficulties:
Has your child been suspended or expelled? from school No Yes from bus No Yes (If yes, please explain)
Has your child ever been tested for special services? No Yes (If yes, when and where?)
Has your child ever been in any type of special education program? No Yes (If yes, please explain)
How does your child feel about school?
How does your child usually do homework?
How do you feel about your child’s educational program?

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IV. Behavior Characteristics and Discipline Strategies:

The following behaviors describe my child (Check all that apply):
Highly responsible Easily frustrated Uncooperative with children
Tries hard to do work Fails to finish things Uncooperative with adults
Makes good use of time Always “up and on the go” Overly sensitive to criticism
Relates well to others “Acts before thinks” Denies mistakes, blames others
Completes tasks Daydreams too much Demands immediate attention
Cooperative A loner Poor control of anger
Sensitive to others’ needs Prefers adult company Talkative or silent
How is your child disciplined at home? (Check all that apply)

Isolation Withholding privileges Grounding
Time-out Stern talking Other (describe)
Spanking Reasoning/explaining
Describe which ways are most effective and why.
Who enforces the rules and is responsible for discipline at home?
V. Family Members:
Mother’s Name: Age: Highest School Grade Completed:
Employer: Working Hours: Job:
Father’s Name: Age: Highest School Grade Completed:

Employer: Working Hours: Job:
Parents are: Married

Separated
Divorced If separated or divorced, who has custody of the child?
Single
Remarried If remarried, when? Mother Father
Please list all people who live in the home with your child:
Name Relationship Age
List others who have frequent contact with your child:
Does your child have any difficulties relating to or getting along with the following: (If yes, please explain)
Parents No Yes
Brothers/sisters No Yes
Other children in your neighborhood No Yes

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V. Home and Community:

What regular chores or responsibilities does your child perform at home?
How well does your child perform these chores or responsibilities?
What extracurricular activities does your child participate in?
What community activities does your child participate in?
Does your child work at a job or a volunteer position? No Yes

Name of employer: Working hours: Job:
Have there been any significant events in the family that have affected your child (such as a recent move, death in the
family, divorce, changes in job or finances, etc)? No Yes (If yes, please explain)
Is the family receiving services from any community agencies? No Yes (If yes, please explain)
Please provide any additional information or comments that will help the school understand and work more effectively with
your child.
Thank you for providing this information—your input and cooperation are appreciated!

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Page 1 of 4

Student: School: Grade:

Form completed by: Relationship to student: Date:

I. Strengths and Concerns:

II. Medical and Developmental History:

Did your child have delays or problems with:

Medications my child is taking:

Revised: January 2008 Social/Dev History

III. School History:

Describe any specific difficulties:

Other schools your child has attended:

Describe any specific difficulties:

How does your child feel about school?

How does your child usually do homework?

How do you feel about your child’s educational program?

Revised: January 2008 Social/Dev History

IV. Behavior Characteristics and Discipline Strategies:

How is your child disciplined at home? (Check all that apply)

Describe which ways are most effective and why.

Who enforces the rules and is responsible for discipline at home?

Father’s Name: Age: Highest School Grade Completed:

Parents are: Married

List others who have frequent contact with your child:

Revised: January 2008 Social/Dev History

V. Home and Community:

How well does your child perform these chores or responsibilities?

What extracurricular activities does your child participate in?

What community activities does your child participate in?

Does your child work at a job or a volunteer position? No Yes

Revised: January 2008 Social/Dev History

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