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Attention Deficit: A Curse And Delight
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Child questionnaire
Patient information form
Adult questionnaire
Vanderbilt initial assessment - Parent
Vanderbilt Follow-up assessment - Parent
Vanderbilt initial assessment - Teacher
Vanderbilt Follow-up assessment - Teacher
The Team
Denise Bernardi , M.Ed.
Michael G. Hehir , Psy.D.
Michael Preston , Ph.D.
Marla Stone , M.A.,CMC.
Robert (Buck) A. Weaver , III, Ph.D.
Linnea Weaver , M.S., CCC-SLP
Beverly Weinberg, M. ED.
Contact
Home
Services
Initial Consultation
Evaluation
School and Professional Advocacy
Self Advocacy Method (SAM)
Therapy Services
Small Group Tutoring
Educational/Organizational Tutoring and Coaching Services
Vocational Evaluations
Follow-Up Services
IEP Info For Parents
Resources
Vested Academics
Articles
>
Attention Deficit: A Curse And Delight
An Autobiography of a Dyslexic Youth
Prisoners of Time
Recommended Reading
Multimedia
>
Blog
Videos
Podcasts
Glossary of Terms
Our Forms
>
Authorization to Release Information
Child questionnaire
Patient information form
Adult questionnaire
Vanderbilt initial assessment - Parent
Vanderbilt Follow-up assessment - Parent
Vanderbilt initial assessment - Teacher
Vanderbilt Follow-up assessment - Teacher
The Team
Denise Bernardi , M.Ed.
Michael G. Hehir , Psy.D.
Michael Preston , Ph.D.
Marla Stone , M.A.,CMC.
Robert (Buck) A. Weaver , III, Ph.D.
Linnea Weaver , M.S., CCC-SLP
Beverly Weinberg, M. ED.
Contact
Adult questionnaire
*
Indicates required field
Date questionnaire completed
*
Your Name
*
First
Last
Last Grade Completed
*
Date of Birth
*
School
*
Person completing questionnaire
*
Who suggested an evaluation at this time?
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CHIEF PROBLEM
*
Do you have any school/work behavior problems? Please describe
*
Do you have any school studies problems (besides chief problem?) Please describe
*
Please describe your weaknesses (other than chief problem)
*
Please describe your strengths:
*
Family history
your:
Age
*
Birthweight
*
Brothers and/or sisters:
Name
*
Age
*
Name
*
Age
*
Name
*
Age
*
Name
*
Age
*
Name
*
Age
*
Are you:
*
Biological
Adopted
Foster child
Who do you live with at present time? (Include parents, brothers, sisters, grandparents, friends, etc.)
*
What is the primary language spoken at home?
*
What is your mother's education?
*
Occupation
*
What is your father's education?
*
Occupation?
*
Pleast list relatives* who are left-handed or "mixed-handed"
*
Please list relatives who have (or had) school problems: (*Family members include: biological parents, siblings, grandparents, aunts, uncles. Please include whether maternal or paternal)
Relatives*
Name: Maternal side
School/Learning Difficulties
(language, reading, writing, spelling, mathematics, foreign languages, etc.)
Name
*
Comment
*
Name
*
Comment
*
Name
*
Comment
*
Name
*
Comment
*
Relatives*
Name: Paternal side
School/Learning Difficulties
(language, reading, writing, spelling, mathematics, foreign languages, etc.)
Name
*
Comment
*
Name
*
Comment
*
Name
*
Comment
*
Name
*
Comment
*
Please list biological relatives with behavior problems
Relatives*
Name: Paternal side
Social/Emotional or Behavioral Difficulties
(overactive, restless, withdrawn, trouble with the law, depression, bipolar/alcohol/substance abuse)
Name
*
Comment
*
Name
*
Comment
*
Name
*
Comment
*
Name
*
Comment
*
Relatives*
Name: Paternal side
Social/Emotional or Behavioral Difficulties
(overactive, restless, withdrawn, trouble with the law, depression, bipolar/alcohol/substance abuse)
Name
*
Comment
*
Name
*
Comment
*
Name
*
Comment
*
Has any relative* suffered from seizures, neurological disease or disorder? If so, please identify, diagnosis, treatment, and relationship
*
Are you the 1st, 2nd,etc. of mother's pregnancies (Please include all pregnancies, miscarriages, if known)
*
Complications in pregnancies (if female)
*
Were you full term (born at expected time)?
*
Yes
No
Weeks premature?
*
Age of mother at delivery?
*
Age of father at delivery?
*
Medical History (Complete all that is known)
Your condition at birth:
*
Did you have jarndice. "Rh" problems, chemical abnormalities?
*
Seizures/convultions
*
At what age?
*
Were seizures associated with high fever?
*
Have you had any serious illnesses? If so, what?
*
When?
*
How long?
*
Have you ever been hospitalized? If so, why?
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When?
*
How long?
*
Have you ever had any operations? If so, what?
*
When?
*
Do you have any allergies? If so, to what?
*
Treatment
*
Have you had any head injuries?
*
Circumstances
*
When?
*
Were you unconscious? If so, how long?
*
Were you dizzy?
*
Did you have headaches?
*
Treatment, if any
*
Do you have abdominal pains/vomiting? If so, how often?
*
When does this occur?
*
How is this treated?
*
How often do you have headaches?
*
When does this occur?
*
How is this treated?
*
Do you have vision problems? (Please specify)
*
Approximate date of last examination
*
Do you have hearing problems? (Please specify)
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Approximate date of last examination
*
Do you have a history of frequent ear infections?
*
How often?
*
When?
*
Treatment
*
Has CHIEF PROBLEM (see top) been treated medically in the past?
*
Yes
No
Describe medication
*
What changes, if any, did you notice?
*
List the medications you currently takes:
*
When medication started:
*
Dosage
*
Prescribing physician's name, address and phone number:
*
Developmental History
As an infant, were you fussy?
*
Yes
No
Over-sleepy/difficult to rouse?
*
Yes
No
Did you respond to cuddling?
*
Yes
No
Compared to other children, did you have problems learning:
To understand language? Please describe
*
To talk? Please describe
*
Gross motor skills (walking, hopping, riding bicycle, etc.)? Please describe
*
Fine motor skills (fastening buttons, zippers, tying shoelaces, drawing, etc.)? Please describe
*
Early school-related skills (naming colors, saying alphabet, recognizing coins, etc.)? Please describe
*
To play/socialize with other children? Please describe
*
To build with blocks, play with puzzles, draw pictures? Please describe
*
Did you have difficulty in leaving parents? At what age? Please describe
*
Did you have toilet training difficulties? (For day? For night?) Please describe
*
Have you had any sleeping difficulties?
*
Have you had any eating difficulties?
*
At what age did child show a clear hand preference?
*
Which hand was preferred?
*
Left
Right
Do you relate better with:
*
older children
younger children
same age children
Do you have the opportunitiy to relate with many peers?
*
Yes
No
Have you ever had psychotherapy or counseling?
*
Yes
No
When?
*
With whom?
*
How often?
*
How long?
*
Was it useful? Please describe
*
May we contact therapist/counselor?
*
Testing History
Please rank your self-esteem (self-confidence) in the following areas (1=low; 5=high):
Academic
*
1
2
3
4
5
Social
*
1
2
3
4
5
Athletic
*
1
2
3
4
5
Family
*
1
2
3
4
5
Have there been any major changes in these areas? When? Please describe
*
Have you ever been evaluated under the provisions of Massachussetts Chapter 766 (CORE)?
*
Yes
No
When (list each time)?
*
Date of most recent evaluation
*
What type(s) of evaluation(s) (e.g. speech and language, reading, etc.)?
*
Educational
Reading
Neurological
Psychological
Fine/gross motor (OT/PT)
Speech & Language
Home Visit
Have there been any prior private (outside school) evaluations?
*
Yes
No
When?
*
Where?
*
What type?
*
School History
Have you ever repeated a grade?
*
Yes
No
What grade?
*
What schooling (if any) did you have before first grade? Please specify
*
In what grade did school problems become noticeable?
*
What specific educational interventions have been made in the past?
*
Type(s) of specialist(s)
*
How ofter?
*
For how long?
*
How many times per week does child receive special education?
*
What types?
*
Have you had change of school program or work? If so, please describe
*
How many schools/jobs have you had?
*
Please list (include grade /type of employment)
*
Your present school or work and full address:
Name of school/work
*
Street
*
City
*
State
*
Zip
*
Who is appropriate contact person for details of your schoolwork or employment?
*
May the clinician call this person to ask about work, etc.?
*
Yes
No
May we send our school/work questionnaire?
*
Yes
No
Are there other school or work personnel whom we should contact? If so, please specify
*
SIgnature
*
Max file size: 20MB
Please upload a scan of your signature
Full name
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Date
*
Submit