Adult History Form

Name

Birth date

Street address

City

State

Zip code

Cell phone

Home phone

Email address

Parent(s) names, addresses:

Emergency contact (name, number address)

Who referred you to Kingfisher Learning?

Why are you seeking a psychoeducational evaluation?

BIRTH DEVELOPMENTAL HISTORY

PREGNANCY

Were you adopted?

Yes No

Age of mother at delivery

Age of father at delivery

Length of mother's pregnancy

Were there any prenatal complications?

Yes No

If yes, please describe?

LABOR & DELIVERY

Birth weight (pound, ounces)

Was birth a caesarean section?

Yes No

If yes, explanation:

Were there any birth complications?

Yes No

If yes, explanation:

Were there any breathing problems?

Yes No

If yes, explanation:

Other complications?

Yes No

If yes, explanation:

DEVELOPMENTAL MILESTONES

Sit alone

Walk alone

Speak first words

Put first words together meaningfully

Talk in complete sentences

Become toilet trained for bladder

Become toilet trained for bowel

Do you have a history of speech or language problems?

Yes No

If yes, please descibe:

Is English your first language?

Yes No

If no, what is your first language?

How old were you when you learned to speak English?

MEDICAL HISTORY

If you answered "yes" to any of the above conditions, please list age and explanation:

Are you currently taking any medications?

Yes No

If yes, please list the name of the medication, dosage, dates, reason and name of prescribing physician:

Have you had any of the following tests?

Eye exam

Hearing test

EEG

MRI

CT scan

If you answered "yes" to any of the tests above, please list the date and test result below:

Have you ever been hospitalized?

Yes No

If yes, please specify the reason for hospitalization, as age:

FAMILY MEDICAL HISTORY

If you answered "yes" to any of the above, please list who (relation to child)

SOCIAL & BEHAVIORAL HISTORY

CLIENT'S BROTHER(S):

Name

Age

Grade

Grades repeated

Learning problems

CLIENT'S SISTER(S):

Name

Age

Grade

Grades repeated

Learning problems

ABOUT YOU

What are your interests/hobbies?

How would you describe your personality?

Have you ever experienced social difficulties either as a child or adult?

Have you received any psychological or psychiatric treatment, i.e. therapy, counseling, etc.?

Yes No

If yes, please list the provider, reason and dates:

EDUCATIONAL HISTORY

At what age did you begin school?

What grade/year are you currently in?

If currently in school, what school do you attend?

School address

City

State

Zip

Please list all schools you have attended:

If you answered "yes" to any of the above, please describe the nature of the problem:

If you had any difficulties in school (academic or behavioral), in what grade did these problems start?

Briefly describe your school experiences with regard to academic performance:

What kind of grades do you typically earn?

Have you ever:

Been in accelerated classes or classes for the gifted?

Been retained in any grade?

Received tutoring?

Received resource support?

Been in a self-contained special education classroom?

If you answered yes to any of the above, please list the grade and add a description:

Have you been tested before for academic, learning or behavioral issues?

Yes No

If yes, please list the evaluator, place of evaluation, date and conclusions:

Have you ever been eligible for special education services?

Yes No

If yes, is it because of (check all that apply):

Learning Disability

Learning Impairment

(intellectually handicapped)

Speech/Language Impairment

Emotional/Behavioral

Other Health Impaired (ADHD)

Please check any special education support or tutoring you have received or are currently receiving:

Reading

Written Language

Math

Speech and Language

Other

If you checked any of the boxes above for special education support or tutoring, please list the grades and description/by whom:

If you are currently a student, complete the following section. Please answer completely and truthfully. It is important to have accurate information in order to best serve you.

1. How is your class attendance?

2. How often do you participate in class (such as answering questions or engaging in a classroom discussion)?

3. Tell me how you prepare for your daily classes.

4. Explain how you prepare for tests (include how, when and where you study.)

5. If you need help, where do you go for assistance? If you do not seek help, can you explain why?

6. What specific difficulties did you face in your classes last semester (or currently)? What challenges are you experiencing or that you foresee with academics this semester?

Do you use a planner/digital calendar?

Yes No

Is there additional information you would like to share that you think will be helpful?

If you have any previous reports to maximize the benefits of this evaluation and to assure that the same tests are not given twice, possibly invalidating results, please upload them here:

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