Student History Confidential

Please complete this information form (front and back). Use the back if needed.

Student Name:

Birth Date:

Date

Current Date:

Date

Age:

Address:

Parents

Mother's Name:

Father's Name:

Are parents divorced or separated?

YesNo

If so, who has custody?

Mother's Phone Number:

Please enter a valid phone number.

Father's Phone Number:

Please enter a valid phone number.

Mother's Email:

example@example.com

Father's Email:

example@example.com

Mother's Occupation:

Father's Occupation:

School:

Grade:

Has s/he repeated a grade?

Did your child:

Speak by two years of age?

YesNo

Have dysfluency? (stutter)

YesNo

Have difficulty learning the alphabet?

YesNo

Have difficulty following directions?

YesNo

Have difficulty memorizing phone number, address, days of the week, months of the year?

YesNo

Describe:

Has your child’s vision been checked?

YesNo

When?

Results?

Has your child’s hearing been checked?

YesNo

When?

Results?

Has your child experienced frequent ear infections?

YesNo

Ear tubes?

YesNo

Have there been any hospitalizations or significant medical problems:

Is there family history of difficulty with reading or spelling? If so, what is that relationship?

Student History Form Confidential