MC EC#5G1

MARSHALL COUNTY SCHOOLS

DEVELOPMENTAL & SOCIAL HISTORY

GENERAL INFORMATION

Student’s Name

Father’s Name Mother’s Name

Occupation Occupation

Employer Employer

Child presently lives with: Both parents Mother Father Other

Is either parent a stepparent? Yes No If “yes” give name

Languages spoken in the home:

Others living in home:

Name / Age / Relationship / Grade Completed

Community services presently or previously received:

Social Services Health Department Family/Youth Services

Social Insurance Mental Health Others (List)

HEALTH AND DEVELOPMENT (Check if present and describe at bottom.)

Natural Adopted

Pregnancy

Falls Excess Bleeding Blackouts Toxemia Emotional Stress

Lack of Prenatal Care Alcohol/Drug Use Premature Overdue

Delivery

Spontaneous Induced Caesarean Breech Unusually Long Labor

Condition of Infant at Birth

Birth Injury/Defect Jaundiced Breathing Problem Low Birth Weight

Other

Early / Average / Late / Early / Average / Late
Walking / Toilet Training
Talking / Speaking in Sentences

Has you child had any of the following: (If “yes”, please describe.)

NO YES

Traumatic experiences (death, accidents, divorce)

Severe illnesses

Seizures or convulsions

Head injuries

High or prolonged fevers

Surgery

Allergies

When was your child’s last physical?

Is your child taking any medicine now?

Child’s current state of health? Excellent Good Fair Poor

Other Comments:

INTERESTS AND ACTIVITIES

Please list some of your child’s interests and hobbies:

Does you child have friends his own age? Yes No

If “no”, are friends usually: Younger Older

Check the characteristics that are like your child/youth:

Happy Cries easily Tantrums Athletic Artistic Overactive

Fights Puts self down Teases others Hits or hurts others Shy

Has many fears Moody Social Other

FAMILY DYNAMICS

Which adult/parent would your child prefer to talk with about a problem?

Who is responsible for discipline in the home?

What discipline measures are most often used (spanking, verbal corrections, etc.)?

Does the child get along well with brothers and sisters?

Are there other adults who have an important part in raising your child? Yes No

If “yes”, who?

What responsibilities does your child have at home?

What time does your child go to bed?

Does your child sleep well? Yes No If “no”, explain.

SCHOOL HISTORY

Did your child have a preschool or Head Start experience? Yes No

If “yes”, describe.

Were any grades repeated? Yes No If “yes”, which one(s)?

Does your child have a problem with tardiness or absenteeism? Yes No

Describe any problems your child is having with school.

Does your child like to come to school? Yes No

How much time does your child spend on homework?

Has your child been previously evaluated? Yes No If “yes”, by whom and when.

______

Parent/Guardian Date