• Social/Developmental History Questionnaire

     

    Please help us better understand your child.  This information will be used for the purpose of identifying educational needs and will be maintained according to Cabarrus County Schools Student Records Policy.  Thank you.

     

    1. GENERAL INFORMATION

    Student Name_____________________________ DOB/Age ____________Grade_____ School ___________________

    Current Address _______________________________________________ How long at this address _______________

    Person completing form ______________________________Relationship to student ____________________________

    Who does child live with: (specify) ______________________________________________________________________

    Parent’s Name __________________________ Age _________ Highest School Grade Completed ______________

    Employer/Occupation _______________________________________ Working Hours __________

    Parent’s Name____________________________ Age _________ Highest School Grade Completed _____________

    Employer/Occupation _______________________________________ Working Hours ___________

    If applicable: Guardian’s name_____________________________________________ Age _________

    Employer/Occupation _______________________________________ Working Hours _______________

    Language(s) spoken in the home _________________________ Primary Language at home                                

    Are biological parents of child currently: □ married □ separated □divorced □ never married

    • If separated or divorced, who has legal custody? □ mother □ father □ other (specify):
    • If separated or divorced, how do you feel your child has adjusted to the separation/divorce?

    ____________________________________________________________________________________________________

    Are there other adults who have a significant part in raising your child? □Yes □No

    If so, please indicate name & relationship (step-parent, grandparent, boy/girlfriend, etc.)                                           

    ____________________________________________________________________________________________________

    List all people who live in the home with your child  Relationship                            Age

    ____________________________________________          ________________________       __________

    ____________________________________________          ________________________       __________

    ____________________________________________          ________________________       __________

    ____________________________________________          ________________________       __________

    ____________________________________________          ________________________       __________

    ____________________________________________          ________________________       __________

    ____________________________________________          ________________________       __________

    ____________________________________________          ________________________       __________

    Have there been any significant changes in the home over the last few years? (Such as new marriages, deaths, births, change homes, family separations/divorce, parent dating, parent job change, financial stress, etc.)                                                                                                                                                                              

    Is the family receiving services from any community agencies (if yes, please explain)? _______________________

    ____________________________________________________________________________________________________

    1. EARLY DEVELOPMENT & HEALTH
    2. Pregnancy and Birth

    Is your child: □ biological child □ adopted child □ foster child □ other: _______________________

    Mother’s age at birth? _____________ Did mother receive routine medical prenatal care? □Yes □ No

    Please specify any medications used during pregnancy and the reason used:                                                                                                                                                                                                                                                                                                                                      

    Pregnancy lasted ______________weeks / months Child’s birth weight: ______pounds _____ounces

    Did child go home from the hospital at the same time as the mother? □Yes □ No

    If No, explain why: ___________________________________________________________________________________

    Please check the conditions below that describe the health of the child and mother during…

    Mother’s Pregnancy

    Child’s Delivery

    Child’s Condition at Birth

    €        No complications

    €        Normal

    €        Normal

    €        Blackouts

    €        Induced labor

    €        Lack of oxygen

    €        Falls

    €        C-section

    €        Breathing problem

    €        Physical injury

    €        Breech birth

    €        Birth injury/defect

    €        Excessive bleeding

    €        Unusually long labor (>12 hours)

    €        Jaundice

    €        Hypertension

    €        Premature # of weeks _______

    €        Newborn ICU # of days _______

    €        Diabetes

    €        Overdue # of weeks ________

    €        Other problem (specify) __________________

    €        Emotional stress

    €        Other problem (specify) __________________________

     

    €        Toxemia

    €        Alcohol &/or drug use

    €        Use of tobacco

    Additional information relating to any of the above checked items __________________________________________ ____________________________________________________________________________________________________

    1. Health

    Describe the state of your child’s current health: □ Excellent □ Good □ Fair □ Poor

    Is your child currently taking any medication? □Yes □ No

    If yes, please list medications: _________________________________________________________________________

                                                                                                                           

    Has your child ever been identified as having a disability? □Yes □ No

    If so, by whom, what age, & what disability? _____________________________________________________________

    ____________________________________________________________________________________________________Has your child ever received psychological counseling and/or therapy? □Yes □ No

    If so, by whom (professional/agency) and when: _________________________________________________________

    ____________________________________________________________________________________________________

    Has your child ever participated in therapy services from a private entity? (i.e., speech, occupational, physical, vision therapy, etc.)? □Yes □ No

     If so, by whom (professional/agency) and when: _________________________________________________________

    ____________________________________________________________________________________________________

    Has your child ever participated in educational services from a private entity (i.e., private tutor, Sylvan Learning Center)? □Yes □ No

     If so, by whom (professional/agency) and when: _________________________________________________________

    ____________________________________________________________________________________________________

    Has your child ever participated in an early intervention program from birth through age 3? □Yes □ No

     If so, by whom (professional/agency) and when: _________________________________________________________

    ________________________________________________________________________________________________________________

     

    Has your child had any of the following?

    (Please check all that apply)

    Please describe and give details, dates, and/or age of onset

    □ Serious &/or Frequent Illnesses

     

    □ Head Injuries

     

    □ Seizures or convulsions

     

    □ Surgery/Hospitalization

     

    □ History of Ear Infections

     

    □ Allergies                            □ Asthma

     

    □ Vision or Hearing Problems

     

    □ Other health problem

     

    1. Development

    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) ____________________________________

    III. BEHAVIOR

    1. Behavior in Infancy

    During your child’s first few years of life, were any of the following present to a significant degree?

    €        Did not enjoy cuddling

    €        Difficult nursing

    €        Was not easily calmed by being held or being rubbed and/or difficult to comfort

    €        Did not copy movements & facial expressions of others 

    €        Did not smile at familiar/unfamiliar people

    €        Did not turn towards caregivers

    €        Colicky

    €        Did not respond to his/her name

    €        Excessive irritability

    €        Did not respond to speech of caregivers

    €        Diminished sleep

    €        Fascination with certain objects

    €        Frequent head banging

    €        Constantly into everything

    * Please describe all checked items                                                                                                                                                                                                                                                                                         

    1. Child’s Early Temperament: (Toddler through five years of age)

    􀂙 Activity Level – How active has your child been from an early age? ______________________________________

    ____________________________________________________________________________________________________

    􀂙 Distractibility – How well was your child able to maintain focus or concentration, or pay attention to tasks?                                                                                                                                                                                    

    􀂙 Adaptability - How well was your child able to deal with transition, change, or when denied his/her own way?           

    ____________________________________________________________________________________________________

    􀂙 Approach/Withdrawal – How well was your child able to respond to new things (i.e., new places, people, food, etc.)? _______________________________________________________________________________________________

    􀂙 Intensity – Whether happy/unhappy, how strong were your child’s feelings exhibited? Were others made aware of when your child was upset, angry, disappointed, etc.? __________________________________________________

    ____________________________________________________________________________________________________

    􀂙 Mood What was your child’s basic mood? Did he/she exhibit frequent or rapid changes in mood or temperament? _______________________________________________________________________________________

    􀂙 Regularity How predictable was your child’s patterns of activity level, sleep, appetite, etc.? ________________

    ____________________________________________________________________________________________________

    1. Current Behavior Characteristics

    Describe your child’s strengths ________________________________________________________________________

    ____________________________________________________________________________________________________

    Extracurricular Activities &/or Community Activities your child participates in _________________________________

    ____________________________________________________________________________________________________

    Favorite Subject Areas/Activities &/or Subjects your child does well in ______________________________________

    ____________________________________________________________________________________________________

    Please check below all behaviors or characteristics that fit your child over the past year:

    €        Fidgets, is easily distracted, has a hard time staying seated, has difficulty waiting for his/her turn

    €        Often depressed/irritable mood

    €        Talks excessively, interrupts often, doesn’t listen

    €        Often loses things, very disorganized compared to others his/her age.

    €        Low energy/fatigue

    €        Shy

    €        Poor concentration

    €        Feeling of worthlessness or low self-esteem

    €        Difficulty initiating tasks

    €        Withdrawn

    €        Difficulty completing tasks

    €        Overly anxious or fearful

    €        Difficulty following instructions

    €        Sleeping too little/insomnia

    €        Engages in impulsive behaviors (acts before thinking)

    €        Sleeping too much

    €        Immature compared to peers

    €        Difficulty making decisions

    €        Engages in physically dangerous activities

    €        Cries easily

    €        Often argumentative with adults

    €        Temper tantrums

    €        Often actively defiant to adult requests and rules

    €        Rapid mood changes/mood swings

    €        Blames others for own mistakes

    €        Suicidal thoughts

    €        Often angry or resentful

    €        Excessive need for reassurance

    €        Frequent complaints of not feeling well

    €        Poor appetite

    €        Excessive separation difficulties

    €        Overeats

    €        Easily frustrated

    €        Explosive temper with minimal provocation

    €        Lies

    €        Odd fascinations

    €        Steals

    €        Unrealistic worry about futures events

    €        Aggressive towards others

    o    Adults

    o    Peers

    €        Substance abuse

    o    Drug

    o    Alcohol

    o    other

    Please explain all checked items:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

    ________________________________________________________________________________________________________________

     

    1. Home Behavior:

    How would you describe your child’s personality at home?                                                                              

    ____________________________________________________________________________________________________

    How does your child get along with brothers/sisters? _____________________________________________________

    List any responsibilities and/or chores your child has at home:                                                                                    

    Does your child do these regularly? ___Yes ___ No

    Does your child need frequent reminders? ___Yes ___No

    Indicate child’s… Bed time? _____PM Wake time? ______ AM    Does child sleep well? ___Yes ___ No

    How much time does your child typically spend on electronic media? _______________________________________

    Watching T V: ______hours/day; Playing video/computer games: ______hours/day; Other: ______hours/day

    1. Social Behavior:

    How would you describe your child’s peer relationships and choice of friends? (i.e. How many friends? What age/genders? Is child shy, outgoing, a leader, a follower, etc.?)                                                                                                                                                                                                                                                           

    ____________________________________________________________________________________________________

    How does your child interact with children in the neighborhood?                                                                                 

     

    1. EDUCATIONAL HISTORY

    How does your child feel about school? _________________________________________________________________

    How motivated do you feel your child is to learn? _________________________________________________________

    About how much time does your child spend on homework each night? _____________________________________

    How much of a struggle is homework? □ Not a struggle □ Sometimes a struggle □ Often struggles

    Did your child attend    _____ Private Home      _____ Daycare              _____ Preschool

    Name of Daycare/Preschool              Child’s Age      Length of time child attended this daycare/preschool

    ______________________________          __________       ______________________________________________

    ______________________________          __________       ______________________________________________

    ______________________________          __________       ______________________________________________

    Describe any specific difficulties ____________________________________________________________________________________________________

    Schools your child has attended                    Child’s Grade  Length of time child attended this school

    _________________________________    ____________    _________________________________________________

    _________________________________    ____________    _________________________________________________

    _________________________________    ____________    _________________________________________________

    _________________________________    ____________    _________________________________________________

    _________________________________    ____________    _________________________________________________

    Describe any specific difficulties ____________________________________________________________________________________________________