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Attention Deficit: A Curse And Delight
An Autobiography of a Dyslexic Youth
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Child questionnaire
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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
Medical history
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Indicates required field
Patient's Name
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First
Last
Person completing form
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Date of birth
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Birth weight
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Length of pregnancy in weeks
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Relationship to patient
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Please explain any "yes" answers to the following questions about the patient.
Any problems with pregnancy, laboy, or delivery
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Yes
No
Comment
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Any congenital abnormalities? (present from birth or noted shortly after, and which have persisted?)
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Yes
No
Comment
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Any hospitalizations (overnight stays)?
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Yes
No
Comment
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Any surgery?
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Yes
No
Comment
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ANy history of head trauma or concussion?
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Yes
No
Comment
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Any history of seizures?
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Yes
No
Comment
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Elevated lead level? (over 10)
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Yes
No
Comment
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Sleep problems, including insomnia or loud snoring?
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Option 1
Option 2
Option 3
Comment
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Any history within the past few years of poor growth?
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Yes
No
Comment
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Is the patient overweight?
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Yes
No
Is the patient underweight?
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Yes
No
Comment
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Has the patient had a school or sports physical, or an "annual exam" within the past two years? If not, the patient should have one scheduled.
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Yes
No
Comment
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Has the patient had an exam by an eye doctor within the past five years?
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Yes
No
Comment
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Did the patient pass the school hearing test?
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Yes
No
Comment
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Any chronic medical problems in the past that are now under control?
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Yes
No
Comment
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Is the patient on any medication(s) now, including over the counter medications and herbal remedies?
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Yes
No
Comment
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Does the patient have a history of any cardiac problems?
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Yes
No
Comment
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Any medical problems for which the patient is now being treated?
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Yes
No
Comment
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Allergies to medications?
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Yes
No
Which drug(s)?
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Describe the reaction(s)
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Any medications taken for psychological or behavior problems in the past?
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Yes
No
Type of problem being treated
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Please describe in following order: Medicine, Dose, How long on it, Effectiveness, Side effects
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Family History (includes patient's parents, grandparents, aunts, uncles and siblings)
Psychiatric problems?
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Yes
No
Please give relationship to patien, diagnosis, approximate age at diagnosis, need for psychiatric hospitalization, any medications that were noted to help the relative's condition, how the relative has done with regards to the illness in general. Problems would include ADHD, anxiety, depression, substance abuse.
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History of sudden death
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Yes
No
Comment
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Seizure disorders
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Yes
No
Comment
*
Signature
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Date
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