Child Neuro phych

Child Neuropsychological form

Patient’s Full Name:

Date:

Email Parent’s Full Name (Mother, Father):

Address:

City:

State:

Zipcode:

Email (Mother):

Email (Father):

Phone (Mother):

Phone (Father):

Pediatrician Full Name:

Practice Address:

Age:

Birth Date:

Sex: Male Female Other

Grade:

Ethnic/Racial Background:

Primary Language:

Secondary Language:

Hand used for writing: Right Left

Current problem areas/areas of concern:

Early History

Adopted: Yes No

Duration of Pregnancy (in number of Weeks):

Complications during pregnancy:
Excessive Vomiting
Threatened Miscarriage
Excessive Staining/Blood Loss
Hospitalizations
Accidents or Injuries
Toxemia
Other Illnesses

Smoking during pregnancy: Yes No Number of cigarettes per day:

Alcohol use during pregnancy: Yes No Amount per week:

Medications/drugs during pregnancy:

Type of Delivery:

Vaginal Cesarean (Explain if Cesarean):

Was labor spontaneous or induced? Spontaneous Induced

Length of Labor:

Complications during delivery:
None
Breech
Forceps
Intraventricular Hemorrhage (IVH)
Retinopathy
BPD/Lungs
PDA/Cardiac
Cord Around Neck
Other (Explain):

Birth Weight: lbs, oz

Apgar Scores: (if known)

Post-Delivery

Cyanosis (turned blue)? Yes No

Infection? Yes No (If yes, please specify):

Other illnesses or problems:

How many days was your child in the hospital nursery before being discharged home?

Difficulty with feeding? Yes No (If yes, please explain):

Developmental and Medical History

Age child crawled: sat: and walked:

Did your child walk prior to 15 months? Yes No

Age child said first word and talked in 2-3 word sentences:

Did your child speak first words (mama, dada) prior to 12 months? Yes No

Did your child speak in 2-3 word sentences prior to 2 years old? Yes No

Does your child use gestures to help communicate their wants and needs? Yes No

Age child was toilet trained (day): (night):

Do accidents still occur during the day? Yes No

Do accidents still occur at night? Yes No

Did your child receive Early Intervention (EI) services prior to age 3? Yes No

Select which type of EI services received:
Speech
Occupational
Physical

Did your child receive interventions after age 3 through the school or privately? Yes No

Select which type of intervention received:
Speech
Occupational
Physical

Conditions Check

Does your child show any of these conditions? (Check all that apply):
Attention Problems
Head Injury
Muscle Tightness or Weakness
Clumsiness
Hearing Problems
Speech Problems
Frequent Ear Infections
Learning Disability
Behavior Issues
Other Problems:

Has your child ever been tested for developmental disabilities? (e.g., cerebral palsy, specific learning disabilities, autism, ADHD, etc) Yes No

Medical History

Please list past and current medical Conditions:

Has your child ever been hospitalized? Yes No
If yes, describe:

Has your child ever suffered a serious injury to their head? Yes No
If yes, describe:

Medications

Please note all medications taken at present, their dosage, and frequency given. Example: Depakote 100 mg. 2 tablets/ AM, 1.5 tablets/ afternoon, 4 tablets/ evening.

Name	Dosage/Amount	Frequency Given

Family History

Please check all that existed in close biological family members (parents, brothers, sisters, grandparents, aunts, uncles), note who it was, and describe the problem indicated:

Physical/Psychiatric Problems	Who	Description
Neurological/Brain Condition
Learning Disability
Mental Retardation
ADHD
Alcohol/Drug dependency
Bipolar Disorder
Depression
Personality Disorder
Schizophrenia
Other Psychiatric Illness
Other Disease/ Disorder

Psychosocial History

People living in household with child:

Name	Age	Relationship to Child

Would you consider the current living situation stressful? Yes No Maybe

What is your child's best attribute/characteristic (e.g., friendly, hardworker) ?

What is your child's worst attribute/characteristic? (e.g., stubborn, quick tempered)

Describe any organizations, volunteering, hobbies, reading interests, or other leisure-time activities in which your child is currently engaged:

Psychological/Psychiatric Symptoms and Services

Has your child ever been under the care of a psychiatrist, psychologist, or counselor? Yes No

If Yes, what were they seen for?

Are they currently under the care of:
Psychiatrist Psychologist/Counselor

Educational History

Name of School:

County:

Classroom Placement: Regular Special (Explain if Special):

Is child homeschooled? Yes No Since when?

Typical grades on report card:

Repeated grades? Yes No If yes, which grade(s)?

Skipped grades? Yes No If yes, which grade(s)?

Easiest subjects:

Difficult subjects:

IEP History? Yes No Section 504 Plan? Yes No

Your child’s IEP/504 is designated under which category at school?
Unknown Autism Other Health Impaired Specific Learning Disability (SLD) Speech/Language Impairment (SLI) Traumatic Brain Injury (TBI) Emotional Disturbance Mental Retardation Orthopedic Deaf/Hearing/Visual/Deaf-Blindness Multiple

During which grade was the IEP established?

Educational tutoring/remedial activities (if any):

Describe any school problems:

Substance Use History

Please check all the drugs your child/adolescent is using or has used in the past:

Substance	Presently Using	Used in the Past	Date
Alcohol
Tobacco
Caffeine
Amphetamines (including diet pills)
Barbiturates (downers)
Cocaine or crack
Hallucinogens/LSD
Inhalants (glue, spray cans, etc.)
Marijuana
Opiate narcotics
PCP (angel dust)
Other drugs: