IDENTIFYING INFORMATION
Student’s Name: Birth Date:
ACADEMIC HISTORY
Preschool Experience:
All schools attended in chronological order:
Grade | School & City/State | Comments |
Retentions:
Prior and present special education or support services?
Reading
Math
Social Work
Birth-age 3
Special Education
Speech & Language
OT/PT
Early Childhood
Other
Current Classroom Functioning (What have the parents been told by the teacher? Include grades and teacher input.)
Does he/she like school? Does he/she get along with teachers? How do you feel your child learns best?
Academic Strengths | Academic Weaknesses |
Does he/she do homework? Does anyone help with homework? When/where does your child study? How would you describe the child’s home study environment? Who helps if needed?
Are there any difficulties in your child getting to and from school? Are there any attendance problems? What do you feel contributes to these?
STUDENT HEALTH STATUS AND HISTORY
Family History of Illnesses (check all that apply and to whom)
Current medical conditions in the family that pose concerns for the child:
Prenatal History
Mother’s general health during pregnancy:
Prenatal care received:
Mother’s symptoms during pregnancy
Medications during pregnancy:
What was life like during pregnancy? (Stressful conditions, family relationships, moves, employments, etc.)
Neonatal Risk Factors
Place of birth: Length of pregnancy:
Type of delivery: Length of labor:
Birth weight of baby: lbs. oz. Length of hospital stay:
Stress to baby (position, cord, oxygen):
Condition at birth (breathing, color, temperature, jaundice, intensive care, Apgar):
Feeding (type, allergies):
Developmental Milestones
Walking unassisted □Early □ Normal □ Late □ Unknown
Crawling □Early □ Normal □ Late □ Unknown
Saying first few words □Early □ Normal □ Late □ Unknown
Talking in simple sentences □Early □ Normal □ Late □ Unknown
Toilet trained □Early □ Normal □ Late □ Unknown
Describe any medical concerns if any:
What medications does the child currently take?
Other Medical Concerns (check all that apply)
Does the student use assistive devices? (wheelchair, hearing aid, touch talker, glasses, etc.)
Date of last physical? Date of last dental exam?
Primary physician and clinic: Phone:
Other health care providers or alternative health practices?
FAMILY LIFE
Who else lives in the child’s home?
Siblings
Name | Age | Relationship | Residence |
History of residence:
Describe the communication process within the family. How does the child fit into this? (Argue, talk at once, talk loud, withdrawn, etc.)
SOCIAL AND EMOTIONAL HISTORY
How would you describe your child’s personality/temperament as an infant/young child? (Energy level, adaptability, frustration, intensity of emotions, moods, etc.)
How would you describe your child’s friends? (Best friends, age of friends, activities? Are they friends from church, school, home, etc.?)
How would you describe your child when in a group? (Leader or follower? Withdrawn? Bossy? How does the group handle conflict?)
What does your child like to do with friends? What does he/she like to do alone? (Organized groups/activities, community, neighborhood, church, sports, etc.? How do they spend quiet time?)
What is he/she good at?
Do you have any concerns about your child’s behavior inside or outside of school?
Circle the following description below that you feel describe your child:
Easily angered
Tense/nervous
Thumb-sucking/nail-biting
Overactive/restless
Chronic worrier
Short attention span
Stealing
Aggressiveness
Shy/withdrawn
Stubborn
Temper tantrums
Defiant
Easily distracted
Impulsive
Easily frustrated
Unhappy/depressed
Good problem solver
Caring to peers
Good with younger children
Helpful at home
Sensitive to others’ feelings
Assertive
Goal-Oriented
Strong self-esteem
Sense of humor
Leadership skills
Hard-working
Energetic
Tries to please others
Good with hands-on activities
Creative/dramatic
Sense of right/wrong
Optimistic
Artistic