Social-Developmental History Questionnaire

Social-Developmental History Questionnaire

Carolina Total Child
Today's Date *

Month Day Year
General Information
Childs Name *

First Name Last Name
Date of Birth *

Month Day Year
Age *
Grade *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Person Providing Information? *

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

Both Parents Mother Father Other
Father's Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Mother's Name *

First Name Last Name
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Guardian's Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com

Please List All People in Child's Immediate Family

Family Member's Name

Relationship
to Child

Age/Grade

Living in
Household?

List All Non-Family Members Living in Household

Non-Family Member's Name

Relationship
to Child

Age/Grade

Are biological parents of child currently? *

Married Separated Divorced Never Married Other
If separated or divorced, who is the primary custodial parent?

Mother Father Other
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?

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? *

Excellent Good Fair Poor
Is your child taking any medication? *

Yes No
If Yes, (Please Specify)
Has your child been identified as having a disability? *

Yes No
If Yes, (Please Specify)
Has your child ever received psychological counseling? *

Yes No
If Yes, (Please Specify)

Has you child had any of the following?

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 cuddling Difficult to comfort Colicky Excessive irritability Diminished sleep Poor eye contact Fascination with certain objects Other
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 behavior Is affectionate with family and friends Responds well to authority Boundless energy Poor judgment Withdrawn and/or sullen Cruelty to animals Disorganized, looses things often Sudden outbursts Physical aggression Frustrated easily Shifts from one activity to another Has difficulty paying attention Fidgets or squirms in seat Appears to daydream or "zone out" often Appears depressed and unhappy much of the time Explosive temperament Frequently complains about aches and pains Appears to have low self-esteem Prefers to be alone ("a loner") Starts fires Lacks motivation Steals or lies Becomes upset with change Fearfulness Frequent peer and/or family conflicts Does not appear to listen to what is being said Always worrying about something Nervous habits (nail biting, hair twirling, etc.) Issues with sexuality Issues with technology (phone, computer, social media, etc.) Other

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

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?

Yes No
Does your child need frequent reminders?

Yes No
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?

Yes No
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?

Yes No
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?

Never Sometimes Often
Does your child receive any special services?
IEP, 504 plan, Gifted/Talented and Honors/AP etc.
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Social-Developmental History Questionnaire

General Information

Health Information

Behavioral Information

Social Behavior

Educational History