Social-Developmental History Questionnaire

Social-Developmental History Questionnaire

Carolina Total Child
Today's Date*

MonthDayYear
General Information
Childs Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Grade*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Providing Information?*

First NameLast Name
Relationship to Child?*
Who Does the Child Live With?*

Both ParentsMotherFatherOther
Father's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Mother's Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Guardian's Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Please List All People in Child's Immediate Family

Rows	Family Member's Name	Relationship to Child	Age/Grade	Living in Household?
1
2
3
4
5
6

List All Non-Family Members Living in Household

Rows	Non-Family Member's Name	Relationship to Child	Age/Grade
1
2
3
4

Are biological parents of child currently?*

MarriedSeparatedDivorcedNever MarriedOther
If separated or divorced, who is the primary custodial parent?

MotherFatherOther
If separated or divorced, how do you feel your child has adjusted?
Are you currently in any form of legal litigation regarding the child/children?
Custody, child support, guardian ad litem, etc.
Have there be any significant changes in the home over the last few years?*
What do you feel are your child's strengths?*
What do you feel are your child's weaknesses?*
Briefly describe your concerns for your child:*

Is there a family history of any of the following?

Rows	Yes	Please describe and give details
Learning Difficulties/Disability
Speech or Language Problem
Developmental Disorder
Emotional Problems
Academic Issues
Drug or Alcohol Addiction

Health Information
Describe the state of your child's current health?*

ExcellentGoodFairPoor
Is your child taking any medication?*

YesNo
If Yes, (Please Specify)
Has your child been identified as having a disability?*

YesNo
If Yes, (Please Specify)
Has your child ever received psychological counseling?*

YesNo
If Yes, (Please Specify)

Has you child had any of the following?

Rows	Yes	Please describe and give details
Head Injury
Seizures
Surgery/Hospitalization
History of Ear Infections
Allergies and/or Asthma
Vision Problems
Hearing Problems
Frequent Nightmares and/or Bedwetting
Other Health Problems

Behavioral Information
During childhood, were any of the following present to a significant degree?

Did not enjoy cuddlingDifficult to comfortColickyExcessive irritabilityDiminished sleepPoor eye contactFascination with certain objectsOther
How active has your child been from an early age?
How well has your child been able to maintain focus or concentration, or pay attention to tasks in school and/or home?
Especially tasks they find challenging, a chore or boring
How well has your child been able to cope with transition, change or denied his/her own way?
How well has your child been able respond to new things?
People, places, things, etc.
How well do you feel your child articulates their emotions?
Anger, happiness, disappointment, fear, failure, loneliness, etc.
Describe your child's basic temperament?
Rapid mood swings or even tempered, etc.
How predictable are your child's patterns?
Activity, sleeping, eating, academics, etc.
Please check all behaviors or characteristics your child has exhibited over the past year

Destructive behaviorIs affectionate with family and friendsResponds well to authorityBoundless energyPoor judgmentWithdrawn and/or sullenCruelty to animalsDisorganized, looses things oftenSudden outburstsPhysical aggressionFrustrated easilyShifts from one activity to anotherHas difficulty paying attentionFidgets or squirms in seatAppears to daydream or "zone out" oftenAppears depressed and unhappy much of the timeExplosive temperamentFrequently complains about aches and painsAppears to have low self-esteemPrefers to be alone ("a loner")Starts firesLacks motivationSteals or liesBecomes upset with changeFearfulnessFrequent peer and/or family conflictsDoes not appear to listen to what is being saidAlways worrying about somethingNervous habits (nail biting, hair twirling, etc.)Issues with sexualityIssues with technology (phone, computer, social media, etc.)Other

How often is each of the following settings a problem for your child?

Rows	Rarely	Sometimes	Frequently	Never
While getting ready for school?
When eating at the dinner table?
When playing by him/herself?
When playing with a sibling or child in neighborhood?
When with a babysitter or daycare?
When in public places?
When in the car?
When told to do something he/she doesn't want to do?
During sit-down or homework time?
When watching TV or playing video games?
When it is time for bed?

How would you describe your child's personality at home?
How does your child get along with siblings, if any?
Which adult would your child prefer to talk about their feelings/problems?
Who is the family member your child feels closest?
Who is the person primarily responsible for discipline in the home?
What is the most effective way to deal with your child's behavior problems in the home?
Talking, positive reinforcement, time-out, grounding, loss of privileges, spanking, etc.
How does your child respond to discipline?
List any "responsibilities" your child has at home?
Taking out trash, vacuum, washing the dog, mowing the lawn, etc.
Does your child do these regularly?

YesNo
Does your child need frequent reminders?

YesNo
What time does your child go to bed?

Hour Minutes

AM/PM Option
What time does your child wake up?

Hour Minutes

AM/PM Option
Does your child sleep well?

YesNo
How much time does your child spend watching TV?
How much time does your child spend playing computer/video games?
How much time does your child spend on their phone?
Texting, social media, youtube, etc.
Have any other members of the family expressed concern about your child's behavior?

YesNo
If Yes, please explain
Social Behavior
How would you describe your child's peer relationships and choice of friends?
How many close friends, age and gender, shy, outgoing, leader, follower, associate with scholars, associate with troublemakers, etc.
How does your child interact with other children in the neighborhood?
Educational History
How does your child feel about school?
How motivated do you feel your child is to learn?
About how much time does your child spend doing homework each night?
How much of a struggle is it for your child to do homework?

NeverSometimesOften
Does your child receive any special services?
IEP, 504 plan, Gifted/Talented and Honors/AP etc.
Should be Empty:

Social-Developmental History Questionnaire

General Information

Health Information

Behavioral Information

Social Behavior

Educational History