ࡱ>  Root Entry( JrZEMatOSTZEZEMMMN0ND ( JrMicrosoft Works MSWorksWPDoc9qSPPTw&&&&i8=/:d&ut&8T SOCIAL/DEVELOPMENTAL HISTORY Department of Special Education/Sevier County Schools Name: _____________________________________ Birthdate: _____________ Date: ________________ Mothers name: _____________________________ Fathers name _______________________________ (Check if applicable):Single ___Separated___Divorced___ Age of above child at time of divorce/separation __ Joint Custody? Yes/No Legal Custody with _________/Physical custody with __________ Please list names of all people living in the home. Name Age Relationship to Child ______________________________________ ____ _________________________________ ______________________________________ ____ _________________________________ ______________________________________ ____ _________________________________ ______________________________________ ____ _________________________________ ______________________________________ ____ _________________________________ Medical History and Childs Background 1. What problems did mother have during pregnancy? (Health, Illnesses, Injuries, Medication) _______________________________________________________________________________________ Was pregnancy full-term? Yes/No How many weeks? _____ C-Section?_____ Forceps? ____ Breech presentation?____Birth weight? ________ Jaundice? _____ If so, treatment? ________________ Any other problems with labor or delivery? ___________________________________________________ 2. List important medical information including serious illnesses, injuries, and hospitalizations such as frequent ear infections, tubes in ears (hearing problems), seizures, allergies, etc.______________________ ______________________________________________________________________________________________________________________________________________________________________________ 3. Has your child ever been diagnosed as ADHD? Yes/No If so, when and by whom? ________________ Please list current medications. _____________________________________________________________ 4. Has your child ever had visual problems or worn glasses? _____________________________________ 5. Were developmental problems noticed? Yes/No If yes, please list ages at which your child first sat unaided ______, walked independently ______, spoke single words (other than mama and dadda)________, talked using 2-3 words ________, and was toilet trained ________________. 6. Has your child experienced learning or academic problems? Yes/No If yes, please describe: _________ _______________________________________________________________________________________ Has your child ever been evaluated/tested? Yes/No If so, when and where? _________________________ Have special education services been provided in the past? Yes/No If yes, describe: ___________________ Describe any behavior problems noticed at home or reported by teachers: ___________________________ _______________________________________________________________________________________ Communication Does your child have any speech or language problems? Yes/No If yes, when was the problem first noticed? _______ Have there been any previous speech/language services? Yes/No If yes, when and where?______________________________________________________________________________ Previous School History Please list previous school(s) attended beginning with preschool/head start/kindergarten: School Grade Location _________________________________ _____ _____________________________________________ _________________________________ _____ _____________________________________________ _________________________________ _____ _____________________________________________ _________________________________ _____ _____________________________________________ Please report any other concerns or relevant information on the back of this page. Return to the school by _______ !"/&; +{u{o{k{f{f{f{a{a{a( ( +Tuw{v{v{v{pl{(  "Y[=-}Uqqkkkeeeeeeeeeeeeee !lT |  Z * +RyyyyyyyyyyssssssysssssRuwyyy+w!"Rw#$%Times New Roman i8=/:i8=/:dCompObjU