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Granville County Schools

Student Study Team

Student History

Students Name: ___________________________________ Teacher: ___________________________________

In order for us to better meet the educational needs of your child, please provide us with the following information

concerning your childs developmental, medical, and school history. Thank you!

Developmental History

During pregnancy with this student:

Was the child premature? ______Yes ______No

If yes, by how many months/weeks? ___________________________________

Were there any complications during delivery? ______Yes ______No

If yes, please explain. ___________________________________

Were forceps or vacuum used during delivery? ______Yes ______No

What 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 problems in the growth or development during the first few years? ______Yes ______No

(Sitting, crawling, walking, talking within normal ranges)

If yes, please explain. ___________________________________

Medical History

Please place a check next to any illness or condition that your child had or currently has. When you check an item,.

Please note the age of when it occurred.

Check Illness Age Check Illness Age

Head Injury ________ Bleeding Problems ________

Allergies

Type(s): ________________

________ Headaches ________

Broken Bones ________ Convulsions ________

Visual Problems ________ Epilepsy ________

Ear Problems ________ Seizures ________

Speech Problems ________ Memory Problems ________

Fainting Spells ________ Bedwetting ________

Loss of Consciousness ________ Extreme Tiredness ________

Concussions ________ Bone/Joint Disease ________

Anemia ________ Meningitis ________

Cancer ________ Diabetes ________

Heart Problems ________ High Blood Pressure ________

Hepatitis/Jaundice ________ Operations

Type(s): ________________

________

Dizziness ________ Hospitalizations

Reason(s): ______________

________

Other: ___________________ ________

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List all of the medications (prescription and over-the-counter) this student is currently taking or has taken within

the past year. Please also provide the reason for the medications.

Current Medications:

_________________________________________________________________

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_________________________________________________________________

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Reason:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

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Medication taken in the past year, but no longer taken:

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Reason:

_________________________________________________________________

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Family History

Please place a check next to any condition that any member of your family has had and note the members

relationship to the child.

Check Condition Relationship to Student

Attention Difficulties _________________________________________________________________

Learning Problems _________________________________________________________________

Depression _________________________________________________________________

Nervous Psychological Problems _________________________________________________________________

Other: ___________________________________________ _________________________________________________________________

School History

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

If yes, where did they go? _______________________________________________________________

Is the student currently attending a program after school (after school, day care, tutoring, etc.)? ______Yes ______No

If yes, where do they go? _______________________________________________________________

Have there been any previous school problems in the following areas:Area 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, which might affect your child. Also list anything else you think would be beneficial for us to know.

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Parent/Guardians Signature Date