Child / Adolescent Neuropsychological Evaluation

This form is confidential.

The following information is a detailed questionnaire on your child's development, medical history, and current functioning. This information will be integrated with the testing results in order to provide a better picture of your child's abilities. Please fill out this questionnaire as completely as you can.

Person filling out this form:

Mother

Father

Stepmother

Stepfather

Other

If Other:

If your child was referred for this evaluation, please list the doctor that referred you:

What are the problems that caused you to seek help for this child?

Child's Family

Child's FIRST Name

Child's LAST Name

Today's Date

Birthdate

Age

Grade

Name of School

Birth Country

Age on arrival in USA if born elsewhere

Birth Weight

Biological Mothers Name

Age

Highest Level of Education Completed:

Occupation

Biological Fathers Name

Age

Highest Level of Education Completed:

Occupation

Marital Status of Biological Parents:

Married/Common Law

Separated

Divorced

Widowed

Other

If other:

If biological parents are separate or divorced:

How old was the child when the separation occurred?

Who has legal custody of the child?

If this child is not living with either biological parent:

Reason

Legal Guardian:

Adoptive Parents

Foster Parents

Other Family Members

Group Home

Other

If other:

Name(s) of legal guardian(s)

List all people currently living in your child's household:

Name, Relationship to Child, Age

If any brothers or sisters are living outside the home, please list their names and ages:

Primary language spoken in the home:

Other languages spoken in the home:

If your child's first language is not English, please complete the following:

Child's first language:

Age at which your child learned English:

Please indicate your child's ethnicity

HAND USE

Please indicate which hand (or foot) your child uses for:

Writing:

Right Left Both (Equal)

Throwing a ball:

Right Left Both (Equal)

Kicking a ball:

Right Left Both (Equal)

Using Scissors:

Right Left Both (Equal)

Is there anyone else in the patient's extended family who is left handed? If yes, please list relationship to patient:

Developmental History

(If your child is adopted, please fill in as much of the following information as you are aware of.)

During pregnancy, did the mother of this child:

Take any medications?

Yes No

Smoke cigarettes?

Yes No

Drink alcoholic beverages?

Yes No

Use recreational drugs?

Yes No

Were there any complications during pregnancy?

Yes

If yes, please explain:

Number of weeks at which baby was born:

Were there any complications during delivery?

Yes

If yes, please explain:

Did mother or baby stay in special or intensive care?

Yes

Please describe any problems:

Were there any concerns/problems in the first few weeks of life? (e.g., feeling?)

Yes

If yes, please explain:

Any concerns/developmental delays in the first few years of life? (e.g., sitting, walking, speaking, toileting)

Yes

If yes, please explain:

Ages at Milestones

Please indicate at what age:

GROSS MOTOR SKILLS

Crawled

Walked Alone

Ran Well

FINE MOTOR SKILLS

Fed self with spoon

Scribbled

Tied Shoe

LANGUAGE

Use single words

Used sentences (2+ words)

Described Activity

SOCIAL/ADAPTIVE SKILL

Potty Trained-Day

Potty Trained-Night

Rate of Development Overall:

Slow

Normal

Fast

Medical History

Vision problems?

Yes

Please describe:

Date of last vision examination:

Hearing problems?

Yes

Please describe:

Date of last hearing examination:

Has your child had any prior illnesses/diseases/medical diagnoses/brain injuries?

Yes

If yes, please explain:

Has your child ever had seizures?

Yes

If yes, please indicate approximate date/age when seizures started:

Date of last seizure

Seizures occur:

Daily

# per day

Monthly

# per month

Weekly

# per week

Other

Specify:

Has your child been hospitalized?

Yes

If yes, please explain:

Has your child had surgery?

Yes

If yes, please explain:

Has there been any recent stressors that you think may be contributing to your child's difficulties?

Yes

If yes, please explain:

Please list any medications your child is currently taking, including dose and reason for medicine:

Please list any therapies or assessments your child has had:

Family Medical History

Check off any illness/condition that any member of the child's immediate or extended family has had

Seizures or Epilepsy

Relationship to child

Attention deficit (ADD)

Relationship to child

Hyperactivity

Relationship to child

Learning disabilities

Relationship to child

Intellectual disability

(formerly MR)

Relationship to child

Depression

Relationship to child

Anxiety

Relationship to child

Behavior problems

(assaults, thefts)

Relationship to child

Alcohol abuse

Relationship to child

Alcohol abuse

Relationship to child

Drug abuse

Relationship to child

Suicide attempt

Relationship to child

Physical abuse

Relationship to child

Sexual abuse

Relationship to child

Schizophrenia

Relationship to child

Bipolar disease

(manic depression)

Relationship to child

Other

Relationship to child

Education History

Please estimate your child's current academic abilities and choose from the drop downs:

If other, please indicate subject:

If there has been a recent change (illness or injury), please estimate your child's previous academic abilities:

If other, please indicate subject:

Attention

Has your child ever had trouble paying attention at school or home?

Yes

If yes, when did this occur?

Has your child ever been diagnosed with an attention disorder?

Yes

If yes, when?

Has your child ever received treatment for attention problems?

Yes

If yes, what/when?

Learning

Has your child ever had trouble learning?

Yes

Has your child ever been diagnosed with a learning disorder?

Yes

If yes, when?

Has your child ever been diagnosed with a learning disorder?

Yes

If yes, when?

Has your child ever received learning assistance in school?

Yes

If yes, please describe:

Has your child ever received tutoring?

Yes

If yes, please describe:

Academic Accommodations/Individual Program or Education Plan

Has your child had a modified learning program?

Yes

Is there an individual program plan (IPP/IEP)?

Yes

If yes, when was it created/implemented?

Has your child ever had a specific Learning Code?

Yes

If yes, indicate code:

Has your child ever been in special education classes?

Yes

If yes, please describe:

Has your child ever been held back a grade?

Yes

If yes, indicate grade:

Classroom Behaviors

Has your child ever been suspended from school?

Yes

If yes, please describe:

Has your child ever been expelled from school?

Yes

If yes, please describe:

Briefly describe classroom or school problems if applicable:

Other Information

Has your child ever been in trouble with the law?

Yes

If yes, please describe:

On average, what percentage of the time does your child comply with requests or commands?

What are your child's assets or strengths?

Behavior Checklist (Current Functioning)

Please check the boxes of behaviors that you believe your child currently exhibits at this time:

Sleeping and Eating

Nightmares

Trouble Sleeping

Eats poorly

Eats Excessively

If checked off any of the following, please desrcibe:

Danger to self or others, purposely harms or injures self, talks about killing self, unusual fears, habits, or mannerisms

Cognitive Checklist (Current Functioning)

Rate your child's current cognitive skills relative to other children of the same age:

Speech

Above Average Average Below Average Severe Problem

Comprehension of speech

Above Average Average Below Average Severe Problem

Problem Solving

Above Average Average Below Average Severe Problem

Attention Span

Above Average Average Below Average Severe Problem

Organizational Skills

Above Average Average Below Average Severe Problem

Remembering Events

Above Average Average Below Average Severe Problem

Remembering Facts

Above Average Average Below Average Severe Problem

Learning from experience

Above Average Average Below Average Severe Problem

Understanding Concepts

Above Average Average Below Average Severe Problem

Overall Intelligence

Above Average Average Below Average Severe Problem

PLEASE COMPLETE THE FOLLOWING INFORMATION ONLY IF YOUR CHILD HAS HAD RECENT INJURY OR CHANGE IN MEDICAL STATUS

If a change has occurred, what is the cause and date of the change?

Behavior Checklist (Prior to an injury or recent change)

Please check the boxes of behaviors that you believe your child exhibited prior to the injury or change:

Sleeping and Eating

Nightmares

Trouble Sleeping

Eats poorly

Eats Excessively

Cognitive Checklist (Prior to an injury or recent changes)

Rate your child's cognitive skills relative to other children of the same age prior to the injury or change of functioning:

Speech

Above Average Average Below Average Severe Problem

Comprehension of speech

Above Average Average Below Average Severe Problem

Problem solving

Above Average Average Below Average Severe Problem

Attention span

Above Average Average Below Average Severe Problem

Organizational skills

Above Average Average Below Average Severe Problem

Remembering events

Above Average Average Below Average Severe Problem

Remembering facts

Above Average Average Below Average Severe Problem

Learning from experience

Above Average Average Below Average Severe Problem

Understanding concepts

Above Average Average Below Average Severe Problem

Overall Intelligence

Above Average Average Below Average Severe Problem

Thank you for filling out this questionnaire.

We appreciate your time and the helpful information you have provided to the neuropsychologist.

Your information will be encrypted.