Granville County Schools

Student Study Team

Student History
Students Name: ___________________________________

Teacher: ___________________________________

In order for us to better meet the educational needs of your child, please provide us with the following information
concerning your childs developmental, medical, and school history. Thank you!
Developmental History
During pregnancy with this student:
Was the child premature? ______Yes ______No
If yes, by how many months/weeks? ___________________________________
Were there any complications during delivery? ______Yes ______No
If yes, please explain. ___________________________________
Were forceps or vacuum used during delivery? ______Yes

______No

What was the childs birth weight? ___________________________________

With this child during infancy:
Were there any feeding problems? ______Yes ______No
Were there any sleeping problems? ______Yes ______No
Were there any problems in the growth or development during the first few years? ______Yes
(Sitting, crawling, walking, talking within normal ranges)
If yes, please explain. ___________________________________

______No

Medical History
Please place a check next to any illness or condition that your child had or currently has. When you check an item,.
Please note the age of when it occurred.
Check

Age
________
________

Check

Illness
Head Injury
Allergies
Type(s): ________________
Broken Bones
Visual Problems
Ear Problems
Speech Problems
Fainting Spells
Loss of Consciousness
Concussions
Anemia
Cancer
Heart Problems
Hepatitis/Jaundice

________
________
________
________
________
________
________
________
________
________
________

Dizziness

________

Illness
Bleeding Problems
Headaches

Age
________
________

Convulsions
Epilepsy
Seizures
Memory Problems
Bedwetting
Extreme Tiredness
Bone/Joint Disease
Meningitis
Diabetes
High Blood Pressure
Operations
Type(s): ________________
Hospitalizations
Reason(s): ______________
Other: ___________________

________
________
________
________
________
________
________
________
________
________
________
________
________

List all of the medications (prescription and over-the-counter) this student is currently taking or has taken within
the past year. Please also provide the reason for the medications.
Current Medications:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Reason:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Medication taken in the past year, but no longer taken:

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Reason:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Family History
Please place a check next to any condition that any member of your family has had and note the members
relationship to the child.
Check Condition
Relationship to Student
Attention Difficulties
_________________________________________________________________

Learning
Problems
_________________________________________________________________

Depression
_________________________________________________________________

Nervous
Psychological
Problems
_________________________________________________________________

Other: ___________________________________________
_________________________________________________________________

School History
Did the student attend pre-kindergarten, pre-school, day care, etc. prior to starting school? ______Yes
If yes, where did they go? _______________________________________________________________

______No

Is the student currently attending a program after school (after school, day care, tutoring, etc.)? ______Yes
If yes, where do they go? _______________________________________________________________
Have there been any previous school problems in the following areas:
Area
Type
When
Academics
_______________________________ _______________________________
Behavior
_______________________________ _______________________________
Attendance
_______________________________ _______________________________

______No

Where
_______________________________
_______________________________
_______________________________

Please note any issues, which you as a parent might have coped with as a child, or may currently be coping with as
an adult, which might affect your child. Also list anything else you think would be beneficial for us to know.
______________________________________________________________________________________________________________________________________
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Parent/Guardians Signature

____________________________________
Date