Developmental History Form

Student Profile
Name: Gender:
Date of Birth: Student ID:
Current School
Grade: Year:
Date of referral:
Date of
admission:

Social development
What play activities does your child enjoy?
 Pretend play
 Gross motor games
 Cognitive activities
 Art & crafts
 Other
 None
The child plays primarily
 Alone
 With other children
Peer group status
 Many friends
 Some friend
 Almost no friend
Any concerns about your child’s behavior?
 No
 Yes
Details _____________________________________________________________________
How do you discipline your child?
 By authoritative means
 By authoritarian means
Emotional/behavioral health
 Attention problems
 Hyperactivity
 Impulsivity
 Sleeping problems
 Nervousness/anxiety
 Depression/sadness
Any concern about child’s behavior/emotional health
 No

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  Yes
Details _____________________________________________________________________
Is the child able to take care of his daily life activities?
 Yes
 No
Family History
Family system
 Joint
 Nuclear
 Single-parent
Socio-economic status
 Upper
 Upper Middle
 Lower Middle
 Lower Upper Lower
 Lower
Cousin marriage
 Yes
 No
Child’s relationship with father ___________
 Close
 Distant
Child’s relationship with mother ___________
 Close
 Distant
Child’s birth order ________________
 1st
 2nd
 3rd
 Other
No. of siblings _________
 Only child
 1
 2
 3
 Other
Child’s relationship with siblings
 Congenial
 Strained
Any sibling/family member suffering from the same problems as child does
 Yes
 No

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Overall family environment
 Peaceful
 Stressful
Educational History
The child started school at the age of
 3.5- 4
 5
 6
 7
 Above 7
Previously school
 None
 Yes
Mention name _______________________________________________________________
Medium at previous school
 English
 Urdu
Relationship with other class-fellows
 Congenial
 Conflicted
Reason for developing Individualized Educational Plan
 Student identified as exceptional
 Student not formally identified but requires special education program/services,
including modified/alternative learning expectations and/or accommodations
Placement Decision
 Regular class with indirect support
 Regular class with resource assistance
 Special education class with partial integration
 Special education class full-time
Subjects to which IEP applies
 English
 Social & Natural Sciences
 Urdu
 Islamiat
 Mathematics
Curriculum status
 Modified
 Accommodated
 Alternative

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