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? *

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: *

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(overactive, restless, withdrawn, trouble with the law, depression, bipolar/alcohol/substance abuse)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(overactive, restless, withdrawn, trouble with the law, depression, bipolar/alcohol/substance abuse)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)? *

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? *

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) *

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? *

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? *

Over-sleepy/difficult to rouse? *

Did you respond to cuddling? *

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? *

Do you relate better with: *

older children younger children same age children

Do you have the opportunitiy to relate with many peers? *

Have you ever had psychotherapy or counseling? *

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 *

Social *

Athletic *

Family *

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)? *

When (list each time)? *

Date of most recent evaluation *

Have there been any prior private (outside school) evaluations? *

When? *

Where? *

What type? *

School History

Have you ever repeated a grade? *

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.? *

May we send our school/work questionnaire? *

Are there other school or work personnel whom we should contact? If so, please specify *

SIgnature *

Max file size: 20MB

Full name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Date *

Submit

Adult questionnaire

Hours

Telephone

Email