Developmental Questionairre for Testing

Identifying and Demographic Information
A. Client Information
Name *
Name
Date of Birth *
Date of Birth
Sex *
Current Address *
Current Address
Home Phone *
Home Phone
Please list the name of the school, address, and phone number if possible.
Handedness *
Ethnicity
If other, please specify your ethnicity.
Biological or Adopted? *
If adopted, at what age?
Please indicate the names of any childcare providers, the age at the time of care, and the length of time.
If you wish us to contact a parent of family member not in the current household, please provide his or her name(s) and phone number(s).
Identifying and Demographic Information
B. Family Demographics
Mothers Name
Mothers Name
Date of Birth
Date of Birth
Home Phone
Home Phone
Work Phone
Work Phone
Fathers Name
Fathers Name
Date of Birth
Date of Birth
Home Phone
Home Phone
Work Phone
Work Phone
Mothers Marital Status
Please check all that apply.
Fathers Marital Status
Please list all adults and children living in the household, including age, gender, and relationship to child.
Identifying and Demographic Information
Referral Information (Who referred you to our service?)
Referral Name
Referral Name
Phone
Phone
Referral Address
Referral Address
Phone
Phone
Presenting Problems
What concerns do you have and why are you seeking help at this time?
What kind of information or assistance are you hoping to obtain?
Are any concerning behaviors or behavior problems? If yes, please describe:
Are there any specific concerns / problems with studying and/or learning problems? If yes, please describe:
Please describe any other problems that may be of relevance to this evaluation:
Please describe three or four strengths:
Please describe two or three weaknesses:
Please list all past neurological, psychiatric, psychological, neuropsychological, eduactional, speech & language, or other types of evaluations administered.
Please list all past or present interventions, treatment, or remediation the child has received or is receiving, including Physical Therapy, Occupational Therapy, Speech, and Language Therapy, etc.:
Developmental History
A. Pregnancy and Birth History
Describe any difficulties in conception and/or complications that occured during pregnancy:
Where any medications used during pregnancy? If yes, what kind?
Was alcohol or other substances used during pregnancy? Describe frequency and type:
Please list in weeks.
Please list in hours.
Please list in Pounds and Ounces:
Please list first and second.
Complications During Birth
Check any of the following complications that occurred during birth:
Where there any complications or difficulties during labor and delivery?
What was the state of the infant's health at birth?
Please list length of stay in hospital listed in days.
Please list length of stay in hospital listed in days.
Developmental History
B. Infancy (0-12 Months) As an infant were any of the following traits/descriptions applicable and if so, please explain:
Developmental History
C. Developmental Milestones
Domain (Motor)
Please list the age and problems, if any:
(Without Training Wheels)
Domain (Toilet Training)
Domain (Language)
Besides "Mama" & "Dada"
Domain (Preschool)
Domain (Play)
Developmental History
D. Developmental Problems Please describe the problem in each that apply.
(Biting, Scratching, Hitting, Kicking)
Educational History
A. Day Care
If yes, give name and location of child caregiver.
Time
If yes, describe:
Educational History
Preschool
If yes, please give name and location of preschool.
Any Problems
If there where problems, please describe:
Educational History
C. Kindergarten
If yes, please give name and location of school:
If yes, describe:
If yes, please describe:
Educational History
List the names and Locations of Schools Attended:
Please list name, location of school, and grades attended:
Please list name, location of school, and grades attended:
Please list name, location of school, and grades attended:
Please list the name and address of current school:
School Phone
School Phone
Teachers Name
Teachers Name
Elementary & High School
Please indicate the following problems if these were school experiences:
Has the Child been retained a grade in school? If yes, when and why?
Has the child skipped a grade in school? If yes, when and why?
Does the child have difficulty with reading? If yes, describe:
Does the child have difficulty with math? If yes, describe?
Has the child been placed in a special education / resource room? If yes, hours per day:
Does the child dislike going to school? If yes, describe:
Educational History
E. Current School or Placement ( via IDEA, IEP, MDC, or Section 504):
Educational History
F. Family Medical History
(Those Taken for Longer than 6 Months)
(Food, Medicine, Other)
Respiratory
lung disease, asthma, shortness of breath, tuberculosis, pneumonia, bronchitis, emphysema, tumor, other
Cardiovascular
heart disease, heart murmur, structural defect, arrhythmia, congestive heart failure, high blood pressure, peripheral vascular disorder, chest pain
Endocrine
thyroid conditions, pituitary disorder, adrenal disease, diabetes, hypoglycemia, tumor
Ear - Nose - Throat
ear infections, hernia, tinnitus, nose bleeds, tonsillitis, laryngitis, structural defect, difficulty swallowing, deafness, tumor
Genitourinary
kidney / bladder disease, tumor, structural defect, bed wetting
Gastrointestinal
ulcers, gastritis, hernia, pancreatitis, colitis, diarrhea, constipation, malabsorption problems, liver / gallbladder disease, tumor, structural defect, cystic fibrosis, stomach aches
Hematologic
anemia, platelet / coagulations disorders, polycythemia, splenic disease, leukemia, lymphoma
Immunological
HIV / AIDS, immune system disease
Integument
discolorations, sores, tumors, pain, itching, rashes, sweating, nail abnormalities
Musculoskeletal
connective tissue disease, arthritis, fibro myositis, osteoporosis, structural defect, scoliosis, tumor, pain
Neurological
headaches, seizures, tics, fainting, narcolepsy, tremors, vertigo, meningitis, encephalitis, stroke, brain hemorrhage, head injury, tumor, toxic metal exposure, coma, loss of consciousness, sleep disorder, cerebral palsy, muscular dystrophy, multiple sclerosis, mental retardation, structural defect, Tourette syndrome, learning disability, ADD / ADHD, autism, hyperlexia, processing deficts, obessesive complusive disorder.
Ocular
blurred vision, double vision, glaucoma, blindness, structural defect, glasses / contact / tumor
Psychiatric
alcohol / drug abuse, emotional / behavior disorders, manic / depression, bipolar disease, schizophrenia, physical / sexual abuse, phobias, panic attacks, anxiety, eating disorder
Other Conditions
high fever >104, genetic disorders, birth defects, other
Educational History
G. Client's Neurological and Psychiatric History
meningitis, encephalitis, stroke, brain hemorrhage, narcolepsy, sleep disorders, head injury, coma, loss consciousness, tumor, toxic metal exposure, headaches, seizures, tics, fainting, tremor, vertigo? If so, describe:
cerebral palsy, muscular dystrophy, multiple sclerosis, mental retardation, central nervous system structural defect? If so, describe:
Tourette syndrome, learning disabilities, dyslexia, ADD/ADHD, autism, Asperger syndrome, hyperlexia, processing deficits, obsessive compulsive disorder, oppositional defiant disorder, nonverbal learning disability, executive function deficits? If so, please describe:
If so, please describe:
emotional/behavior disorders, depression, manic/depression, bipolar disorder, schizophrenia, phobias, panic attacks, anxiety, eating disorder? If so, describe:
Have you (or your child) been a victim of emotional, physical, or sexual abuse? If so, describe:
Educational History
H. Social-Emotional Development
Are there any problems at home?
If yes, please describe:
Are there any social problems with family or peers?
I
If yes, please describe:
Other Children
Is there a preference to be around / play with older, younger, or same age indiviuals / children?
How would you describe your or the clients temperament and personality?
Who is Completing this Form?
Who is Completing this Form?
If not client - then what is your relationship to him or her?
(If Other)