Dr. Medlin - Neuropsychology Intake Form

CONFIDENTIAL FORM - PLEASE COMPLETE THE BELOW FORM IN ITS ENTIRETY

Here you will find a detailed questionnaire on your child's developmental and medical history, as well as current functioning. Dr. Medlin will review this form with you in the interview and integrate this information with the results of the evaluation in order to provide a better understanding of your child's strengths and weaknesses.

Person filling out this form:

Mother

Father

Stepmother

Stepfather

Other

If other:

TODAY'S Date:

Child's FIRST Name:

Child's LAST Name:

Child's Date of Birth:

What are the major concerns that prompted you to seek out this evaluation?

Child's Age:

Grade in School:

Name of School:

Birth Country:

Age of Arrival in United States if born elsewhere:

Child's Family

Biological Mother's Name

Biological Mother's Age

Highest Level of Education Completed

Occupation

Biological Father's Name

Biological Father's Age

Highest Level of Education Completed

Occupation

If Other:

If biological parents are separated or divorced:

How old was the child when the separation occurred?

Who has legal custody of the child?

If the child is not living with either biological parent, please state the reason:

Legal Guardian, if not either biological parent:

Adoptive Parent(s)

Foster Parent(s)

Other Family Member(s)

Group Home

Other

If other, please explain:

Name(s) of Legal Guardian(s)

List of all people currently living in the child's household:

Name, Relationship to Child, Age:

Other siblings living outside of the home (name and age):

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)

Developmental History

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

During the pregnancy, did the mother of the child:

Take any medications?

Yes No

Smoke Cigarettes?

Yes No

If yes, what medication(s)?

Drink alcoholic beverages?

Yes No

Use recreational drugs?

Yes No

If yes, please explain:

Were there any complications during the pregnancy?

Yes

If yes, please explain:

Number of weeks at which baby was born:

Birthweight in pounds:

Were there complications during the delivery?

Yes

Don't Know

If yes, please explain:

Did mother or baby require a NICU stay or prolonged hospitalization?

Yes

Unsure

Please describe any complications and/or treatments required:

Were there any problems or complications in the first few weeks of life? (i.e., feeding, latching, temperament)

Yes

Unsure

If yes, please explain:

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

Yes

Unsure

Developmental Milestones

Please indicate at what age your child met the following milestones:

Gross Motor Skills

Crawled

Walked Alone

Ran Well

Do you presently have any concerns around your child's balance, coordination, running, walking, or skipping? If YES, please explain.

Fine Motor Skills

Fed Self with Spoon

Tied Shoes

Began to Write Letters

Do you presently have any concerns around your child's handwriting, button use, scissors use, or handwriting?

Language

Spoke 1st Words

Used 2 Word Sentences

Spoke in complete, grammatically correct sentences

SOCIAL/ADAPTIVE SKILLS

Toilet Trained-Day

Toilet Trained-Night

Medical History

Vision Problems?

Yes

If yes, please describe:

Date of last vision examination:

Hearing Problems?

Yes

If yes, please describe:

Date of last hearing examination:

Has your child had any prior illnesses, medical complications, brain injuries, and/or medical complications?

Yes

If yes, please explain:

Has your child ever had seizures?

Yes

If yes, at what age/date did seizures begin?

Date of last seizure:

Has your child been diagnosed with epilepsy? If YES, what type?

Seizures Occur:

Daily

Number per day:

Monthly

Number per month:

Weekly

Number per week:

Other

Specify:

Has your child been hospitalized?

Yes

If yes, please explain:

Has your child had surgery?

Yes

If yes, please explain:

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

Yes

If yes, please explain:

Please list any medications your child is presently taking and the reason for taking the medication:

Please list any therapies or assessments your child has had (i.e., physical therapy, occupational therapy, speech and language therapy, ABA, counseling, etc.):

Family Medical History

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

If other family history, please list below:

Education History

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

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

Attention

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

Yes

If yes, when?

Has your child ever been diagnosed with an attention disorder (i.e., ADHD)?

Yes

If yes, what/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, what/when?

Has your child ever received learning assistance in school?

Yes

If yes, what/when?

Has your child ever received tutoring?

Yes

If yes, please describe:

Has your child had a modified learning program?

Yes

If yes, please describe:

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 what grade and why?

Is your child served via an IEP, 504 plan, or similar plan?

Yes

If yes, please list accommodations and when the plan was implemented:

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:

Behavior Checklist (Current Functioning)

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

Nightmares

Challenges falling asleep

Challenges staying asleep

Decreased appetite

Excessive Appetite

Social Development

Prefers to be alone

Difficulties maintaining conversation

Excessively shy or timid

Bullies other children

Difficulty making friends

Not sought out for friendship by peers

Will not approach peers

Teased by other children

Doesn't empathize with others

Difficulty seeing another person's point of view

Doesn't grasp sarcasm or humor

Overly trusting of others

Behavioral/Psychosocial

Poor sense of danger

Spiteful/Vindictive

Irritable, angry, or resentful

Skips school

Frequent tantrums

Purposely harms or injures self (describe below)

Argumentative with adults

Dangerous to others (describe below)

Lying

Throws or destroys things

Stealing

Talks about killing self (describe below)

Low frustration threshold

Runs Away

Excessively worried or anxious

Overly attached to certain objects

Impulsive

Needs a lot of supervision

Unusual fears, habits, or mannerisms (describe below)

Seems depressed

Alcohol abuse

Not affected by negative consequences

Overly preoccupied with details

Drug abuse

If you checked off any of the following, please describe further below:

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/Articulation

Above Average Average Below Average Severe Problems

Comprehension of speech (ability to understand what others are saying and asking)

Above Average Average Below Average Severe Problems

Problem Solving

Above Average Average Below Average Severe Problems

Attention Span

Above Average Average Below Average Severe Problems

Organizational Skills

Above Average Average Below Average Severe Problems

Remembering Facts

Above Average Average Below Average Severe Problems

Remembering Events

Above Average Average Below Average Severe Problems

Learning from experience

Above Average Average Below Average Severe Problems

Understanding Concepts

Above Average Average Below Average Severe Problems

Overall Intelligence

Above Average Average Below Average Severe Problems

Check any specific problems that are currently present:

Poor articulation

Easily distracted

Difficulty finding words to express self

Frequently forgets instructions

Disorganized speech

Ungrammatical speech

Talks like a younger child

Slow learner

Difficulty planning tasks

Frequently loses belongings

Doesn't foresee consequences of actions

Slow thinking

PLEASE COMPLETE THE FOLLOWING INFORMATION ONLY IF YOUR CHILD HAS HAD A 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:

Sleep and Eating

Nightmares

Challenges falling asleep

Challenges staying asleep

Decreased appetite

Excessive appetite

Social Development

Prefers to be alone

Difficulties maintaining conversation

Excessively shy or timid

Bullies Other Children

Difficulty making friends

Not sought out for friendship by peers

Will not approach peers

Teased by other children

Doesn't empathize with others

Difficulty seeing another person's point of view

Doesn't grasp sarcasm or humor

Overly trusting of others

Behavior/Psychosocial

Poor sense of danger

Skips school

Irritable, angry, or resentful

Spiteful/Vindictive

Frequent tantrums

Purposely harms or injures self (please describe below)

Argumentative with adults

Dangerous to others (describe below)

Lying

Throws or destroys things

Stealing

Talks about killing self (describe below)

Low frustration threshold

Runs away

Excessively worried or anxious

Overly attached to certain objects

Impulsive

Needs a lot of supervision

Unusual fears, habits, or mannerisms (describe below)

Seems depressed

Not affected by negative consequences

Overly preoccupied with details

Alcohol abuse

Drug abuse

If you checked off any of the following, please describe further below:

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

Cognitive Checklist (Prior to an injury or recent changes)

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

Speech/Articulation

Above Average Average Below Average Severe Problems

Comprehension of speech (ability to understand what others are saying and asking)

Above Average Average Below Average Severe Problems

Problem Solving

Above Average Average Below Average Severe Problems

Attention Span

Above Average Average Below Average Severe Problems

Organizational Skills

Above Average Average Below Average Severe Problems

Remembering Facts

Above Average Average Below Average Severe Problems

Remembering events

Above Average Average Below Average Severe Problems

Learning from experience

Above Average Average Below Average Severe Problems

Understanding Concepts

Above Average Average Below Average Severe Problems

Overall Intelligence

Above Average Average Below Average Severe Problems

Check any specific problems that are currently present:

Poor articulation

Easily distracted

Difficulty finding words to express self

Frequently forgets instructions

Disorganized speech

Ungrammatical speech

Talks like a younger child

Slow learner

Difficulty planning tasks

Frequently loses belongings

Slow thinking

Doesn't foresee consequences of actions

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