<p> BRANTLEY COUNTY SCHOOLS Special Education Department</p><p>Social and Developmental History</p><p>Student: ______DOB: ______</p><p>Family History: 1. Parents/Guardian(s) ______</p><p>Address ______</p><p>Phone ______</p><p>2. Student lives with: Mother Father Both Parents / Other: ______</p><p>3. Has any immediate or extended family member had any emotional, mental, or learning problems? ______If yes, please explain (who, when, type). ______</p><p>4. Marital History (divorces, dates of remarriage, separations, problems, etc…) ______5. Any other family problem(s) (financial, legal, etc…) ______6. Siblings (Brothers and sisters including step and half siblings): Name Age Sex Relationship School ______</p><p>7. Other adult(s) in the home and relationship ______</p><p>School History: 1. Attitude towards school ______2. Best Subject ______Worst subject ______3. School Transfers? ______Retention(s)? ______4. Describe any learning problems as seen by parent(s)/guardian(s) ______Medical and Developmental History: 1. Pregnancy (List any problems) ______2. Any use of medications, tobacco, alcohol, or other substances during pregnancy? ______If yes, what amount and frequency? ______3. Labor (long, short, difficult, normal)? ______4. Term of pregnancy (full-term, etc…) ______Birth (natural, caesarian, etc…) ______5. Any complications with child? ______6. Developmental milestones: Age crawled: ______Age talked (words) ______Age toilet trained ______Age walked: ______Age talked (sentences) ______Age stopped bed wetting ______FORM QQ 1</p><p>7. Unusual childhood diseases (high fevers, etc…) ______8. Medical Problem(s)? (seizures, injuries, respiratory or physical problems, ADHD, etc…) ______If yes, please explain ______9. Speech problems? ______Hearing Problems? ______10. Is child presently taking medication(s)? ______If yes, please list ______</p><p>Social/Emotional/Behavioral Development: 1. Is child excessively dependent? ______If yes, describe ______2. Is child excessively fearful? ______If yes, explain ______3. Is child generally happy? ______If no, explain ______4. Does child require excessive attention for his/her age? ______5. Does child have adequate self-control for his/her age? ______6. Describe any behavior problems observed within the home ______Adaptive Behavior Functioning: 1. Does child have trouble with independent functioning (feeding, bathing, toileting, etc…) ____ 2. Does child have motor skill deficiencies (sitting, standing, writing, using scissors, etc…) ____ 3. Does child have difficulty communicating with others? ______4. Does child have difficulty interacting socially with others? ______5. Does child have difficulty with being self-directed? (Completes work independently, returns borrowed items, initiates activities, etc…) ______</p><p>Please provide any additional information you would like for us to know about your child: ______</p><p>Please list any concerns you have regarding your child’s education: ______</p><p>______Signature of Person Providing Information / Relationship to Student Date</p><p>FORM QQ2</p>