Social History

Social History
Interest and Accomplishments
Peer Relationships
Home Behavior
Developmental History
Medical History
Community Behavior
Please check the items your child can do:

Social History

Child’s Name:____________________________________________________________

Date of Birth:________________ Person completing this form:_____________________

Marital Status of Parents:___________________________________________________

If parents are separated or divorced, how old was the child when the separation occurred:
________________________________________________________________________

List all people living in house:
Name Relationship to Child Age
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Interest and Accomplishments

What are your child’s main hobbies and interests?_______________________________
________________________________________________________________________

What does your child enjoy doing most?_______________________________________
________________________________________________________________________

What does your child dislike doing most?______________________________________
________________________________________________________________________

What are your child’s strengths?______________________________________________
________________________________________________________________________

Peer Relationships

Does your child seek friendship with peers? Yes No
Is your child sought by peers for friendship? Yes No
Does your child play with children his/her age? Yes No

Younger Older

Describe briefly any problems your child may have with peers?_____________________ ________________________________________________________________________

Home Behavior

All children exhibit, to some degree, the kinds of behavior listed below. Check those that you believe your child exhibits to an excessive or exaggerated degree when compared to other children his/her own age:

Hyperactivity Poor Attention Span Impulsivity
Poor Memory Low frustration Threshold Temper Outbursts
Interrupts frequently Sloppy table manners Does not listen when spoken to
Heedless of Danger Excessive number of accidents More active than siblings
Sudden outburst of physical abuse to other children Does not learn from experiences
Acts like he/she is driven by a motor
Wears out shoes more frequently than siblings

Developmental History

During pregnancy, was mother on medication? Yes No
If yes, what kind?________________________________________________________________
During pregnancy, did mother:
Smoke? Yes No Drink alcoholic beverages? Yes No
Use Drugs? Yes No
Were forceps used during delivery? Yes No
Was a Cesarean section performed? Yes No
If yes, for what reason?___________________________________________________________
Was child premature? Yes No
If so, by how many months?_______________________________________________________
What was the child’s birth weight?__________________________________________________
Were there any birth defects of complications? Yes No
If yes, please describe:____________________________________________________________
______________________________________________________________________________
Were there any feeding or sleeping problems? Yes No
If yes, please describe,:___________________________________________________________
______________________________________________________________________________
Where there any problems in growth and development of the child during the first few years?
Yes No If yes, please describe:________________________________________
______________________________________________________________________________
Please list any illnesses or condition that your child has had or been diagnosed with:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Is your child taking any medication? Yes No
If yes, indicate kind and reason: ____________________________________________________
______________________________________________________________________________

The following is a list of infant and preschool behaviors. Please check (X) if the skill was developmentally appropriate or delayed and if possible the age at which it first occurred.

Behavior	Developmentally Appropriate	Delayed	Age
Showed response to mother
Rolled over
Sat alone
Crawled
Walked alone
Babbled
Spoke first word
Put several words together
Dressed self
Become toilet trained
Stayed dry at night
Fed self

Medical History

Has your child or a close relative had any of the following: Please specify who.
Allergies ____________________ Diabetes ___________________
Anemia ____________________ Asthma ___________________
Seizure/Convulsions ____________________ Heart Disease ___________________
Bedwetting ____________________ Sleep Problems ___________________
Eye Problems ____________________ Alcoholism ___________________
Cancer ____________________ High Blood Pressure ___________________
Liver Disease ____________________ Mental Retardation ___________________
Head Injuries ____________________ Sleeping Problems ___________________
Birth Defects ____________________

Describe in detail the areas that you checked:__________________________________________
______________________________________________________________________________
List any hospitalizations, serious illnesses or accidents your child has had:___________________
______________________________________________________________________________

Community Behavior

How does your child act in other community settings besides at school or home? ______________________________________________________________________________
______________________________________________________________________________
Has your child ever been in trouble with the law? If so, please describe:_____________________
______________________________________________________________________________
Do you think your child has age-appropriate skills? Please explain: ________________________
______________________________________________________________________________

Complete the section below only if your child is age 6 or under. Please sign and date the form at the bottom.

Please check the items your child can do:
Point to 4 or 5 body parts
Match 3 basic colors
Points to basic colors
Demonstrates in, on, & under
Builds tower of 3 or more blocks
Builds tower of 6 or more blocks
Imitates a drawn circle
Uses language to obtain objects
Unbuttons large buttons
Can undress self
Can put 3 or 4 piece puzzles together
Rides tricycle
Responds to ?’s about name & age
Rote counts to 5
Rote counts to 10
Hops on either foot
Matches pairs of pictures
Uses and, so, or but to join sentences _______________________________________
Throws ball overhand Signature of person completing this form
Catches large ball
Runs, gallops, jumps _______________________________________
Sorts objects by color and shape Date