Many learning difficulties and emotional disturbances have a hereditary component. Have any family members had any of the following?
If yes, please specify family member's relationship to this child. If child is not residing with biological parents, please include health information on biological parents if known.
From the age of five to the present time, were/are there any special problems noted in the following areas? If yes, please describe.
Does your child demonstrate the following qualities? If no, please describe.
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