PEDIATRIC NEUROPSYCHOLOGY HISTORY FORM
Name of Child:
Date of Birth:
Home Address:
Home phone number:
GENERAL INFORMATION:
Child’s place of birth:
Mother’s Name:
Work/cell number:
Father’s Name:
Work/cell number:
Who has legal custody of the child?
Child lives with (Please circle all that apply):
Natural mother
Natural father
Stepmother
Adoptive mother
Adoptive father
Other:
REFERRAL INFORMATION:
Referred by:
Reason for consultation:
What concerns you about your child (if different than the reason for the consultation:
EDUCATIONAL/CULTURAL INFORMATION:
What language(s) is/are spoken at home?
What language are you most comfortable with to receive information?
What language is your child most comfortable with to receive information?
Stepfather
Pediatric Neuropsychology History Form
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In what ways do you feel you would best be able to learn about your child’s treatment? (Check all that apply)
□ Demonstration
□ Instruction with Return Demonstration
□ Verbal Information
□ Written Information
□ Other:
Do you have any religious or cultural needs related to you child’s care to which we need to be aware? (i.e. diet, religious
practices)
□ Yes (if yes, please explain below)
□ No
PREGNANCY/BIRTH HISTORY:
Is this child adopted?
Y
Was the child born on time?
N
Y
N;
if no:
Child’s birth weight:
weeks early/
Regular Nursery
weeks late
OR
Intensive Care Nursery (circle one)
Age of the mother at time of delivery:
Type of delivery:
Vaginal
Caesarean
Induced
If caesarean or induced, please indicate reason:
Did any of the following occur?
□ Breathing problems
□ Breach birth
□ Cord around the neck
□ Hemorrhage
□ Injury to baby
□ Fetal distress
Were you given any drugs to easy the pain during labor?
□ Forceps required
□ Yellow in color (jaundice)
□ Blue in color
Y
N
(If yes, which drug:
During the pregnancy, did any of the following occur (please circle all that apply):
□ Anemia
□ Threatened miscarriage
□ High blood pressure
□ Blood loss or staining
□ RH Incompatibility
□ Toxemia
□ High blood sugar/diabetes
□ Other illness (specify):
□ Cigarette Use (specify):
□ Alcohol use (beyond occasional drink):
□ Hospitalization required (specify):
□ Operations (specify):
□ Infections (specify):
□ Other illness (specify):
POST NATAL AND INFANCY HISTORY:
Number of days in the hospital
At birth, this baby received (please indicate):
□ Oxygen
□ Transfusions
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# of days:
# of days:
□ Respirator
□ Phototherapy (lights)
# of days:
# of days:
)
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□ Resuscitation
□ Other complications while the baby was still in the hospital:
TEMPERAMENT:
Was the child an easy baby meaning did he/she cry a lot? Did she follow a schedule fairly well?
□ Very Easy
□ Easy
□ Average
□ Difficult
□ Very difficult
How did he/she behave with other people?
□ More sociable than average
□ Average sociability
□ More unsociable than average
When he/she wanted something, how insistent was he/she?
□ Very insistent
□ Pretty Insistent
□ Average
□ Not very insistent
□ Not insistent at all
□ Less Active
□ Not active
How would you rate the activity level of the child as an infant/toddler?
□ Very active
□ Active
□ Average
DEVELOPMENTAL HISTORY:
Please indicate the age at which your child did the following:
Roll over
Sit alone
Crawl
First words
Two word phrases
Sentences
Button & zipper clothes
Tie shoe laces
Walk alone
Alternate feet while ascending stairs
Ride a tricycle
Ride a bicycle without training wheels
Toilet trained
Accidents?: (circle one – if any)
bowel/urine
day/night
Does your child have any difficulty performing age appropriate activities listed below? (Please check all that apply)
□ Bathing
□ Climbing Stairs
□ Communicating
□ Dressing
□ Social Interacting
□ Reaching
□ Running
□ Sitting
□ Sleeping
HANDEDNESS:
Which hand does your child prefer for writing?
□ Right Hand
□ Left Hand
□ Either/No Preference
Which hand does your child prefer for throwing a ball?
□ Right Hand
□ Left Hand
□ Either/No Preference
Which hand does your child prefer for kicking a ball?
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□ Toileting
□ Using utensils
□ Walking
□ Feeding themselves
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□ Right Hand
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□ Left Hand
□ Either/No Preference
MEDICAL HISTORY:
Allergies: Y
N
Please list:
Does your child have a diagnosis: Y
N
Please list
Is your child currently on any medication? Y
N
_____________
Please list:
____________________________________________________________________________________________________
Other history (please check all that apply):
□ Frequent ear infections
□ Ever unconscious
□ Stitches
□ Headaches
□ Scarlet fever
□ Pneumonia
□ Tubes in ears
□ Head injuries/concussions
□ Eye glasses
□ Stomach aches
□ Mumps
□ Lead Poisoning
□ Tonsils/adenoids removed?
□ Fractures
□ Any difficulty hearing
□ Staring spells
□ Chicken Pox
□ Encephalitis
□ Pain
□ Colic
□ Failure to thrive
□ Broken bones
□ Measles
Age at each hospitalization:
Date of first seizure:
Has your child been involved in any serious accidents?
Are your child’s immunizations up to date?
Has your child ever had a head injury requiring medical attention?
If yes, was there loss of consciousness (blackout)?
What tests or procedures were performed?
At what age did this occur?
Did you notice any long standing problems after the injury?
If yes, please describe:
Describe other Medical conditions/problems not listed above: ____________________________________________________
Is your child being seen by any doctor/medical personnel other than a pediatrician/family practitioner? (if yes, please check all
that apply):
□ Neurosurgeon
□ Physical Therapist
□ Dentist
□ Neurologist
□ Psychologist/Psychiatrist
□ Rheumatologist
□ Ear, Nose & Throat
□ Occupational Therapist
□ Speech Therapist
□ Other:
□ For what reason do you see the above practitioner? _______________________________________________
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Pediatric Neuropsychology History Form
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Please answer the following:
How is your child’s hearing?
How is your child’s vision?
How are your child’s gross motor skills?
How is your child’s fine motor coordination?
How is your child’s speech articulation?
□ Good
□ Fair
□ Poor
□ Good
□ Fair
□ Poor
□ Good
□ Fair
□ Poor
□ Good
□ Fair
□ Poor
□ Good
□ Fair
□ Poor
□ Yes
□ No
□ Yes
□ No
□ Yes
□ No
Is there any suspicion of alcohol or drug use?
Is there any history of sexual abuse?
Has your child had any chronic health problems (e.g. asthma, diabetes, heart condition)?
List all chronic illnesses your child suffers from _______________________________________________________________
____________________________________________________________________________________________________
At what age was the onset of any chronic illness?
EDUCATIONAL HISTORY:
Please summarize you child’s progress (e.g. academic, social, and testing) within each of these grade levels:
Preschool:
Kindergarten:
Grades 1-3:
Grades 4-6:
Grades 7-12:
What school does your child attend?
What grade is your child currently in?
Has your child ever been evaluated by a child study team?
Does your child have a 504 plan in place?
Y
Y
N
N
When?
Does your child have an IEP?
Y
N
Has your child ever been in and type of special education program, and if so, how long?
□ Learning disabilities class
(duration
)
□ Basic Skills
(duration
□ Behavioral/emotional disorders class
(duration
)
□ Other (please specify:
)
(duration
)
Does your child receive any services in school? (Please check all that apply)
□ Occupational Therapy
□ Speech Therapy
□ Physical Therapy
□ Other:
Has your child ever been suspended from school?
Y
N # of suspensions?
Has your child ever been expelled from school?
Y
N # of expulsions?
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□ Resource room
(duration
)
)
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Has your child ever been retained in a grade?
Y
N # of retentions?
Have any additional instructional modifications been attempted?
□ None
□ Daily/weekly report card
□ Behavior modification program
□ Other (specify:
)
EVALUATIONS & TREATMENT HISTORY:
Has your child ever been prescribed any of the following? Please list duration in months next to medication.
□ Ritalin (duration
)
□ Tranquilizers (duration
)
□ Dexedrine (duration
)
□ Anticonvulsants (duration
)
□ Cylert (duration
)
□ Antihistamines (duration
)
□ Other prescription drugs – specify
(duration
)
□ List adverse reactions to drugs (if any):
Has your child ever had any of the following forms of psychological treatment? Please list duration next to the
treatment.
□ Individual psychotherapy
□ Group psychotherapy
□ Family therapy with child
(duration
(duration
(duration
)
□ Inpatient evaluation/Rx
)
)
□ Residential treatment
(duration of inpatient stay
)
(duration of placement
)
Please list the start date and current frequency for the following (if applicable):
Physical Therapy:
Speech Therapy:
times per week
times per week
Occupational Therapy:
times per week
Counseling:
times per month
Please list the dates and results for the following (if applicable):
Child study team:
Does child attend resource room? Y
EEG:
CT scan or MRI:
N
Receive basic skills? Y
N
Other evaluations:
FAMILY HISTORY:
Parents’ marital status (circle one):
Married
Separated
Divorced
Living Together
Other_________________________________________________
Mother:
Occupation:
Personal History: Please check any that apply:
□ Seizures
□ Difficulty with Math
□ Depression
□
□ Spelling difficulty
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□ Headaches
□ Reading Problems
□ Anxiety
□
Highest grade completed in school:
□ Speech problems in childhood
□ Spelling Difficulty
□ Bipolar Disorder
□
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Other Medical Conditions:_________________________________________________________________________
Name of mother’s parents, sisters, brothers, nieces, and nephews with problems similar to your child:
Father:
Occupation:
Personal History: Please check any that apply:
□ Seizures
□ Difficulty with Math
□ Learning Problems
□ Headaches
□ Reading Problems
□ Speech problem in childhood
□ Spelling Difficulty
□ Attention Problems
Highest grade completed in school:
Other Medical Conditions:_____________________________________________________________________________
Name of mother’s parents, sisters, brothers, nieces, and nephews with problems similar to your child:
____
____
Please list your child’s siblings:
Name
Age
Medications (if any)
School/grade
1.
2.
3.
4.
5.
SOCIAL HISTORY:
Where does your child live?
House
Does any one in the household(s) smoke?
Y
Apartment
N
Please list below the names and ages of all individuals living in the household:
Name
Who is the primary caretaker(s) for your child?
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Age
Other
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Does the place where you child lives have any of the following? (Please check all that apply):
□ Elevator
□ Stairs, no rail
□ Ramp
□ Stairs, rail
□ Other obstacles:
Does your child utilize any of the following specialized equipment? (Please check all that apply):
□ Bath chair
□ Hearing aid
□ Walker
□ Cane
□ Specialized stroller
□ Wheelchair: (circle one)
□ Crutches
□ Stander
Manual or Power
□ Other:
Is your child involved in any community activities? If yes, please list below:
□ Clubs:
□ Sports:
□ Other:
Does your child receive any special services? If yes, please list below:
Does your child use a car/booster seat? (for children under 80 lbs.)
Y
N
Does your child use a seatbelt? (for children over 80 lbs.)
Y
N
CURRENT BEHAVIORAL CONCERNS:
□ Hyperactive?
□ Could be taken to public places without difficulty at ages 3, 4, 5?
□ Does child attend preschool?
□ Any problems?
□ Chores assigned?
□ Does chores without being asked?
□ Needs reminders?
□ Difficulty making friends?
□ Difficulty keeping friends?
□ Difficulty falling asleep?
□ Difficulty staying asleep?
□ Snores?
□ Difficult to awaken in the morning?
□ Takes naps?
If yes, at what age?
□ Gets ready for school in the morning without supervision?
□ Needs an adult to be present?
Average time spent on homework
Teacher suggested time for homework
Please list all grades that were repeated:
Grade in which school difficulty first arose?:
Does your child have any health problems that could impact on services?
Is there any significant family history that could impact on your child’s services?
Primary concerns
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Other (related) concerns
Pediatric Neuropsychology History Form
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What strategies have been implemented to address these problems?
□ Verbal reprimands
□ Physical punishment
□ Time out (isolation)
□ Acquiescence to child
□ Removal of privileges
□ Avoidance of child
□ Rewards
On the average, what percentage of the time does your child comply with initial commands?
□ 0-20%
□ 60-80%
□ 20-40%
□ 80-100%
□ 40-60%
To what extent are you and your spouse consistent with respect to disciplinary strategies?
□ Most of the time
□ Some of the time
□ None of the time
Have any of the following “stress events” occurred within the past 12 months?
□ Parents divorced/separated
□ Parent changed job
□ Family financial problems
□ Family accident/illness
□ Changed schools
□ Other (specify):
□ Death in the family
□ Family moved
Which of the following are considered to be a problem for your child?
□ Fidgets
□ Difficulty awaiting turn
□ Shifts from one activity to another
□ Often interrupts or intrudes on others
□ Often engages in physically
dangerous activities
□ Difficulty remaining seated
□ Difficulty following instructions
□ Difficulty playing quietly
□ Often does not listen
□ Often blurts out answers to questions
□ Easily distracted
□ Difficulty sustaining attention
□ Often talks excessively
□ Often loses things
before they have been completed
When did these problems begin? (Specify age):
Which of the following are considered to be a problem for your child?
□ Often loses temper
□ Is often angry or resentful
□ Often argues with adults
□ Is often spiteful or vindictive
□ Often blames others for own mistakes
□ Often swears or uses obscene
□ Often actively defies or refuses adult
□ Is often touchy or easily annoyed by
□ Often deliberately does things that
language
requests of rules.
others
annoy other people
When did these problems begin? (Specify age):
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Which of the following are considered to be a problem for your child?
□ Stolen without confrontation
□ Often truant
□ Used a weapon in a fight
□ Stolen with confrontation
□ Lies often
□ Breaking and entering
□ Cruel to animals
□ Physically cruel to people
□ Deliberate fire-setting
□ Destroyed others’ property
□ Often initiates physical fights
□ Run away from home overnight at
least twice
□ Forced someone else into sexual
activity
When did these problems begin? (Specify age):
Which of the following are considered to be a problem for your child?
□ Persistent school refusal
□ Repeated nightmares re: separation
□ Excessive distress when separated
from attachment figure
□ Persistent refusal to sleep alone
□ Somatic complaints
□ Unrealistic and persistent worry about
possible harm to attachment figures
□ Persistent avoidance of being alone
□ Excessive distress in anticipation of
separation from attachment figure
□ Unrealistic and persistent worry that a
calamitous even will separate the
child from attachment figure
When did these problems begin? (Specify age):
Which of the following are considered to be a problem for your child?
□ Unrealistic worry about future events
□ Marked self-consciousness
□ Somatic complaints
□ Excessive need to reassurance
□ Marked inability to relax
□ Unrealistic concern about
competence
□ Unrealistic concern about
appropriateness of past behavior
When did these problems begin? (Specify age):
Which of the following are considered to be a problem for your child?
□ Depressed or irritable mood most of
□ Diminished pleasure in activities
□ Decrease or increase in appetite
□ Insomnia or hypersomnia nearly
□ Psychomotor agitation or retardation
associated with possible failure to
make weight gain
□ Fatigue or loss of energy
every day
□ Feelings of worthlessness or
excessive inappropriate guilt
□ Diminished ability to concentrate
□ Suicidal ideation or attempt
the day, nearly every day
When did these problems begin? (Specify age):
Which of the following are considered to be a problem for your child?
□ Depressed or irritable mood for most
□ Poor appetite or overeating
□ Insomnia or hypersomnia
of the day x1 year
□ Low energy or fatigue
□ Low self-esteem
□ Poor concentration or difficulty
making decisions
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Pediatric Neuropsychology History Form
□ Feelings of hopelessness
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□ Never without symptoms for > 2
months over a 1-year period
When did these problems begin? (Specify age):
OTHER CONCERNS:
Has your child exhibited any of the following symptoms below?
□ Stereotyped mannerisms
□ Compulsive rituals
□ Excessive reaction to noise or fails to
react to loud noises
□ Odd postures
□ Vocal tics
□ Obsessive behavior (concerns for
cleanliness, symmetry, etc. getting
things just right)
□ Overreacts to touch
□ Motor tics
□ Overfocuses on parts of toys,
machines, computers, etc.
TOTAL=
Has your child exhibited any of the following symptoms below?
□ Loose thinking (e.g., tangential ideas,
circumstantial speech)
□ Incoherent speech (mumbles, jargon)
□ Bizarre ideas (e.g., odd fascinations,
delusions, hallucinations)
□ Disoriented, confused, staring, or
“spacey”
TOTAL=
Has your child exhibited any of the following symptoms below?
□ Excessive lability w/o reference to
□ Explosive temper with minimal
□ Excessive clinging, attachment, or
environment
□ Unusual fears
□ Excessively constricted or bland
affect
provocation
□ Strange aversions
□ Situationally inappropriate emotions
□ Panic attacks
dependence on adults
TOTAL=
Has your child exhibited any of the following symptoms below?
□ Little or no interest in peers
□ Qualitatively abnormal social
behavior
□ Significantly indiscreet remarks
□ Excessive reaction to changes in
routing
□ Abnormalities of speech
□ Initiates or terminates interactions
inappropriately
□ Self-injurious behaviors
TOTAL=
Has your child exhibited any of the following symptoms below?
□ Little or no interest in peers
□ Qualitatively abnormal social
behavior
□ Significantly indiscreet remarks
□ Excessive reaction to changes in
routing
□ Abnormalities of speech
□ Initiates or terminates interactions
inappropriately
□ Self-injurious behaviors
TOTAL=
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Pediatric Neuropsychology History Form
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Which of the following are considered to be a problem for your child at the present time?
□ Difficulty going to sleep
□ Difficulty staying asleep
□ Difficulty getting up in the morning
□ Bedtime bed-wetting
□ Painful legs/urge to move
□ Co-sleeping
□ Frequent snoring at night
□ Gasping/choking for air
□ Excessive daytime sleepiness
□ Loss of muscle tone to
□ Body/head rocking
□ Bedtime resistance
□ Awaken screaming or confused
□ Sleep Walking
□ Sleep talking
□ Teeth grinding (bruxism)
□ Nightmares
TOTAL=
Parent’s Signature
Date
Printed name of person completing this form
Relationship to child
PATERNAL RELATIVES:
For the following, please indicate if the statement or condition to the left corresponds to any of the family members listed.
SIBLINGS
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TOTAL
Pediatric Neuropsychology History Form
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Self
Mother
Father
Problems with aggressiveness, defiance,
and oppositional behavior as a child
□
□
Problems with attentions, activity, and
impulse control as a child.
□
Learning disabilities
Bro
Bro
Sis
Sis
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Failed to graduate from high school
□
□
□
□
□
□
□
Mental retardation
□
□
□
□
□
□
□
Psychosis or schizophrenia
□
□
□
□
□
□
□
Depression for greater than 2 weeks
□
□
□
□
□
□
□
Anxiety disorder that impaired judgment
□
□
□
□
□
□
□
Tics or Tourette’s
□
□
□
□
□
□
□
Alcohol abuse
□
□
□
□
□
□
□
Substance abuse
□
□
□
□
□
□
□
Antisocial behavior (assaults, thefts, etc.)
□
□
□
□
□
□
□
Arrests
□
□
□
□
□
□
□
Physical abuse
□
□
□
□
□
□
□
Sexual abuse
□
□
□
□
□
□
□
MATERNAL RELATIVES:
For the following, please indicate if the statement or condition to the left corresponds to any of the family members listed.
SIBLINGS
Self
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Mother
Father
Bro
Bro
Sis
Sis
TOTAL
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Problems with aggressiveness, defiance,
and oppositional behavior as a child
□
□
□
□
□
□
□
Problems with attentions, activity, and
impulse control as a child.
□
□
□
□
□
□
□
Learning disabilities
□
□
□
□
□
□
□
Failed to graduate from high school
□
□
□
□
□
□
□
Mental retardation
□
□
□
□
□
□
□
Psychosis or schizophrenia
□
□
□
□
□
□
□
Depression for greater than 2 weeks
□
□
□
□
□
□
□
Anxiety disorder that impaired judgment
□
□
□
□
□
□
□
Tics or Tourette’s
□
□
□
□
□
□
□
Alcohol abuse
□
□
□
□
□
□
□
Substance abuse
□
□
□
□
□
□
□
Antisocial behavior (assaults, thefts, etc.)
□
□
□
□
□
□
□
Arrests
□
□
□
□
□
□
□
Physical abuse
□
□
□
□
□
□
□
Sexual abuse
□
□
□
□
□
□
□
SIBLINGS:
For the following, please indicate if the statement or condition to the left corresponds to any of the family members listed.
Brother
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Brother
Sister
Sister
TOTAL
Pediatric Neuropsychology History Form
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Problems with aggressiveness, defiance,
and oppositional behavior as a child
□
□
□
□
Problems with attentions, activity, and
impulse control as a child.
□
□
□
□
Learning disabilities
□
□
□
□
Failed to graduate from high school
□
□
□
□
Mental retardation
□
□
□
□
Psychosis or schizophrenia
□
□
□
□
Depression for greater than 2 weeks
□
□
□
□
Anxiety disorder that impaired judgment
□
□
□
□
Tics or Tourette’s
□
□
□
□
Alcohol abuse
□
□
□
□
Substance abuse
□
□
□
□
Antisocial behavior (assaults, thefts, etc.)
□
□
□
□
Arrests
□
□
□
□
Physical abuse
□
□
□
□
Sexual abuse
□
□
□
□
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