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Granville County SchoolsExceptional Children Program

Social and Developmental History

Students Name: _______________________________ Teacher: _________________________

Date of Birth: ________/_______/_______ School: ________________________ Grade: ____________

In order for us to better meet the educational needs of your child, please provide us with the following information concerning youchilds developmental, medical, and school history. Thank you.

Developmental HistoryDuring pregnancy with this student:

Was the child premature? Yes NoIf so, by how many months/weeks? _________________________________________

Were there any complications for the child during delivery? Yes NoIf yes, please explain_____________________________________________________

Were forceps used during delivery? Yes NoWhat was the childs birth weight? __________________________________________

With this child during infancy:

Were there any feeding problems? Yes No Were there any sleeping problems? Yes No Were there any special problems in the growth or development during the first few years? Yes No

(Sitting, crawling, walking, talking within normal ranges, behavior, activity level, attention)If yes, please explain _____________________________________________________

Medical HistoryPlease check next to any illness or condition that your child had or currently has. When you check an item, please note the age of thechild when it occurred.

Check Illness/Condition Age Check Illness/Condition Age Head injury _____ Dizziness _____ Allergies _____ Headaches _____

Types _____________________ Convulsions _____ Broken Bones _____ Epilepsy _____ Visual Problems _____ Seizures _____ Ear Problems _____ Insomnia _____ Speech Problems _____ Bedwetting _____ Fainting Spells _____ Extreme tiredness _____ Loss of Consciousness _____ Bone/Joint Disease _____ Concussion(s) _____ Meningitis _____ Anemia _____ Diabetes _____ Cancer _____ High Blood Pressure _____ Heart Problems _____ Bleeding Problems _____ Hepatitis/Jaundice _____ Overweight Operations, list types: _____ Underweight Other: _________________________________ Hospitalization(s)-Reasons

Other: _________________________________ Other: __________________________________

GCS00Updated: July 201

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Family Dynamics

Is there any change in the number of siblings, family members or others in your home recently? Yes No

If yes, how many? _______ How is this affecting your child? ______________________________________________________

Medication Information

List all of the medications (prescription and over-the-counter) this student is currently taking and anything taken in the past year and the

reason they are/were taking it.

Current Medications Reason Past Medications Reason Stopped

School History (School-Age Children Only)

Did the student attend pre-kindergarten, pre-school, day care, etc. prior to starting school?

Yes No If, yes, where did they go? ___________________________________________________________________

Have there been any previous school problems in the following areas:

Areas Type When Where

Academics _________________________ ______________________ ____________________________

Behavior _________________________ ______________________ ____________________________

Attendance _________________________ ______________________ ____________________________

Please note any issues which you as a parent might have coped with as a child, or may currently be coping with as an adult, whichmight affect your child. Also note anything else you think would be beneficial for us to know.

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Parent/Guardians Signature Date

GCS00Updated: July 201