CHILD
NEUROPSYCHOLOGICAL HISTORY

	Child’s name  						    Date  			
	Address (Street, City, ST, Zip)  								
	Parent / guardian phone  (H)  				   (W)  			
	Email 												
	Age  		    Birthdate  		    Religion  				  Sex 		
	School  						    Grade 						Medication 											

	Hand child uses for writing / drawing: Right            Left            Switches   		
	Primary language  				   Secondary language   			

	Medical diagnosis  (1)  									
	  	if any	         (2)  									
	Who referred the child for this testing?   							
	Describe the problems, first major concerns and then minor ones.  			

													

	What specific questions would you like answered by this evaluation?
 	(1)  												
	(2)  												
	(3)  												

THIS FORM HAS BEEN COMPLETED BY:

	Name  					    Relationship to child  			
	Address  											
	Phone  (H)  					    (W)  					

SYMPTOM SURVEY

For each symptom that applies to the child, place a check in the box.  Compare the child to other children of the same age.  Then, check if this is a NEW symptom  (within the past year)  or an OLD symptom (over one year).  Add any helpful comments next the item.

PROBLEM SOLVING
New		Old
				Difficulty figuring out how to do new things
				Difficulty making decisions
				Difficulty solving problems a younger child can do
				Difficulty understanding explanations
				Difficulty doing things in the right order (sequencing)
				Difficulty verbally describing the steps involved in doing something
				Difficulty completing an activity in a reasonable period of time
				Difficulty changing a plan or activity when necessary
				Is slow to learn new things
				Difficulty switching from one activity to another activity
				Easily frustrated
				Other problem solving difficulties  					

SPEECH, LANGUAGE, AND MATH SKILLS
New		Old
				Difficulty speaking clearly
				Difficulty finding the right word to say
				Not talking
				Rambles on and on without saying much
				Jumps from topic to topic
				Odd or unusual language or vocal sounds
				Difficulty understanding what others are saying
				Difficulty understanding what he/she is reading
				Difficulty writing letters or words
				Difficulty reading letters or words
				Difficulty with spelling
				Difficulty with math
				Other speech, language, or math problems:  			

SPATIAL SKILLS
New		Old
				Confusion telling right from left
				Has difficulty with puzzles, Legos, blocks, or similar games
				Problems drawing or copying
				Doesn’t know his/her colors
				Difficulty dressing (not due to physical difficulty)
				Problems finding his/her way around places he/she has been to before
				Difficulty  recognizing objects
				Seems unable to recognize facial or body expressions of disapproval 						or emotions
				Gets lost easily												Other spatial problems:  						

AWARENESS AND CONCENTRATION
New		Old
				Easily distracted by:   Sounds          Sights          Physical sensations 	
				Mind appears to go blank at times
				Loses train of thought
				Difficulty concentrating on what others say, but can sit in front of a TV for long 					periods
				Attention starts out OK but can’t keep it up
				Other attention or concentration problems:  				

MEMORY
New		Old
				Forgets where he/she leaves things
				Forgets things that happened recently (e.g., last meal)
				Forgets things that happened days/weeks ago
				Forgets what he/she is supposed to be doing
				Forgets names more than most people do
				Forgets school assignments
				Forgets instructions
				Other memory problems:  						

MOTOR AND COORDINATION
New		Old
				Poor fine motor skills (e.g., using a pencil or crayon)	
				Clumsy
				Weakness
				Tremor
				Muscles are tight or spastic
				Odd movements (posturing, peculiar hand movements, etc.)
				Drops things more than most children
				Has an unusual walk
				Balance problems
				Other motor or coordination problems:  					

SENSORY
New		Old
				Needs to squint or move closer to page to read
				Problems seeing objects
				Loss of feeling
				Problems hearing sounds
				Difficulty telling hot from cold
				Difficulty smelling odors
				Difficulty tasting food
				Overly sensitive to:    Touch____         Light____         Noise_____      
				Other sensory problems:						

PHYSICAL
New		Old									    How often?
				Frequently complains of headaches or nausea				
				Has dizzy spells								
				Has pains in joints	Where?						
				Excessive tiredness
				Frequent urination or drinking
				Other physical problems:						

BEHAVIOR
New		Old						New	      	Old
	      		    Aggressive							   Nervous
			    Attached to things, not people     				   Quiet						    Bedwetting							   Unmotivated	
			    Bizarre behavior						   Resists change
			    Bowel movements in underwear				   Risk-taking	
			    Dependent							   Self-mutilates
			    Depressed							   Self-stimulates
			    Eating habits are poor					   Shy and withdrawn
			    Emotional							   Sleeping habits are poor
			    Fearful							   Swears a lot
			    Immature							   Nightmares, night
											   terrors, sleepwalks
			    Other unusual behavior:  								

Below, check all the descriptions of the child that have been present for at least the past 6 months.  These behaviors should occur more frequently than in other children of the same age:

	    Is very fidgety							    Steals things without people  
	    Can’t remain seated						    knowing on several occasions
	    Doesn’t listen to other people					    Often runs away from his    	    Is cruel to other people					                parents’ home and stays away
	    Highly distractible							    overnight
	    Can’t wait for his/her turn when playing with others		    Easily lies to others
	    Answers before he/she hears the whole question			    Firesetting	
	    Rarely follows others’ instructions					    Doesn’t go to school	
	    Has a hard time concentrating for long periods			    Breaks into other people’s 
	    Destroys other people’s property in some				    property			  	    manner other than by fire						    Starts fights with others
	    Goes from one activity to another without finishing		    Is cruel to animals
	    anything								    Will steal directly from people
	    Frequently makes noise when playing				    Has forceable sexual relations 	    Seems like he/she is always talking				    with others				    When fighting, has used a 						    Is often rude or interrupts 	  	    others weapon on more than 1 occasion				    Seems like he/she frequently is	    Frequently does dangerous things without			    losing things that are need for	    considering the consequences					    school										
Overall, the child’s symptoms have developed:		   Slowly				   Quickly

The symptoms occur:						   Occasionally				   Often

Over the past 6 months the symptoms have:  
							  Stayed about the same		    Worsened

PREGNANCY

Mother’s age at child’s birth:				Father’s age at child’s birth:			

Before the pregnancy, what medications (prescribed or over-the-counter) did the mother take?
List all medications used:											

While pregnant, what medications (prescribed or over-the-counter) did the mother take?
List all medications used:											

How often did the mother see her doctor during the pregnancy?
Regularly (as scheduled by the doctor)_____		Rarely______		Not at all______

During the pregnancy, which of the following did the mother use?	    Amount and Daily Frequency

			 Alcohol										
			 Caffeine (coffee, colas, etc.)								
			 Marijuana													 Recreational drugs (cocaine, heroin, etc.)									 Tobacco										

During the pregnancy, the mother’s diet was:			Good 			Poor 		
If poor, explain:												

The mother’s general physical health during the pregnancy was:	Good 			Poor 		
If poor, explain:												

About how much weight did the mother gain while she was pregnant?			 lbs.

During this pregnancy, check all the mother had:
	    Accident							    Diabetes
	    Anemia							    High blood pressure
	    Bleeding (severe or frequent spotting)			    Illnesses or infections
	    Preeclampsia, eclampsia, or toxemia			    Psychological problems
	    Surgery							    Vomiting (severe or frequent)

How many pregnancies did the mother have prior to this one?
Number of live births:  		
Number of miscarriages:  		

BIRTHS

Was this child born:
Early  	  		How early?  		 weeks
On time  		(38 - 42 weeks)
Late       		How late?    		 Weeks

How much did the baby weigh at birth?		  lbs.		  oz.	OR		  gms.

How long did the labor last?  											

The labor was:	  Easy 			Moderately difficult 			Very difficult 		

What type of medication was the mother given to help with delivery?	   None 		
Demerol _____       Gas _____       Regional nerve (spinal) block _____       Tranquilizer _____        Epidural _____

Were forceps used during delivery?	Yes ________		No ________

Was the baby born:
Head first     _____		Transverse (crosswise) _____		Posterior first         _____
Breech birth _____		Caesarean section        _____		Vacuum extraction _____
Other: 														

														

Did the baby experience any of these problems:
Fetal distress _____			Low placenta (Placenta previa) _____	Prolapsed cord _____
Premature separation of placenta (Abruptio placenta) _____	    Cord wrapped around neck _____

Describe any other special problems the mother or child had during delivery:

														

At birth, did the baby:
Have difficulty breathing?	Yes _____	No _____
Fail to cry?			Yes _____	No _____
Appear inactive?		Yes _____	No _____

List the baby’s Apgar scores:	 1st _________		      2nd _________

If the father or mother noticed anything unusual when they first saw the baby, describe:

														

If the baby was born with any problems (congenital defects, large or small head, blue baby, bleeding in brain, etc.), describe: 												

Describe any special problems that the baby had in the first few days following birth:

														

Describe any special care, treatment, or equipment the child was given after birth:

														

How long did the baby stay in the hospital? 									

DEVELOPMENTAL HISTORY

For each area, indicate the child’s health by circling one description.  The “Average” period is only a rough idea of what is average since every developmental milestone actually involves a range of several months (e.g., walking occurs approximately 9-18 months of age).  Circle “Early” or “Late” only if you are sure the child’s development was different from that of most other children.

GROSS MOTOR SKILLS
	Crawled				Early			Average (6-9 months)			Late
	Walked alone (2-3 steps)		Early			Average (9-18 months)		Late

LANGUAGE
	Followed simple commands		Early			Average (12-18 months)		Late
	Used single-word sentences		Early			Average (12-24 months)		Late

SELF-HELP
	Toilet trained				Early			Average (13-36 months)		Late

List any other significant developmental problems:

														

Overall, the child’s development was:	Early _______	        Average _______            Late _______

As an infant or toddler, did the child have poor muscle control (i.e., weakness) of the :
Neck _______         Trunk _______         Legs _______         Arms _______

As an infant or toddler, did the child’s muscles seem to be unusually tight or stiff?
Yes _____	No _____	If yes, describe:								

Toilet training was:		Easy _______			Difficult _______

As an infant or toddler, the child was:	Too calm and inactive         		_______
						Calm and reasonably active  		_______
						Irritable and very active          	_______

As a toddler, the child was:			Shy and inhibited	         		_______
						Neither shy nor outgoing        	_______
						Very outgoing and like people 	_______

Did the child have a poor appetite as a baby?					Yes _____     No _____
Did the child fail to gain weight steadily as a baby?					Yes _____     No _____
List the baby’s illnesses or physical problems during the first year:

														

Has the child had a temperature of 104oF (40oC) or higher for more than a few hours?
	Yes _____     No _____     If yes, what age(s)? __________ and how long did it last ___________

Has the child ever been hit hard on the head or suffered a head injury?		Yes _____     No ____
	If yes, what age(s)? ___________       Did the child lose consciousness?	Yes _____     No 	
	How did it happen? 											
	What problems did the child have (physical or mental) afterwards?

Did the child ever have a seizure due to a fever or unknown cause?		Yes _____     No ____
	If yes, describe (age, nature of seizure): 								

Has the child been diagnosed with seizures or epilepsy?				Yes _____     No ____
	If yes, which type?   Partial seizure _____   Generalized seizure _____   Unclassified type 	
	If medication is used, what medication(s)? 								
	Has the child ever had a bad reaction to this medication?			Yes _____     No ____
	If yes, describe:  											

Was the child ever in the hospital for an accident, injury, or operation?		Yes _____     No ____
	If yes, what age(s)? _______		What happened? 						

Has the child ever swallowed any poison, non-food, or drug accidentally?		Yes _____     No ____
	If yes, what age(s)? _______		What happened: 						

Did the child have frequent ear infections?						Yes _____     No ____
	If yes, what age(s)? _______		How often and severe? 					
	What treatment was provided? 									

Please check all the following diseases or conditions the child has ever had:
____ Allergies		   ____ Cerebral palsy	____ Jaundice			____ Mumps
____ Anemia		   ____ Chicken pox		____ Kidney disorder		____ Oxygen deprivation
____ Asthma		   ____ Colds (excessive)	____ Leukemia		____ Pneumonia
____ Bleeding disorder ____ Diabetes		____ Liver disorder		____ Rheumatic fever
____ Blood disorder	   ____ Encephalitis		____ Lung disorder		____ Scarlet fever
____ Brain disorder	   ____ Enzyme deficiency	____ Measles			____ Tuberculosis
____ Broken bones	   ____ Genetic disorder	____ Meningitis		____ Venereal disease
____ Cancer		   ____ Heart disorder		____ Metabolic disorder	____ Whooping cough
Other problems: 												

As the child has been growing up, he/she has been sick:
Much of the time ______		An average amount ______			Not much at all _____

SCHOOL HISTORY

Please summarize the child’s progress (e.g., academic, social, testing) within each of these grade levels (include school name, if possible):

Preschool													

Kindergarten													

Grades 1 through 3												

Grades 4 through 6												

Grades 7 through 12												

Has the child ever been in any type of special educational program, and if so, how long?  (If yes, please explain.)
	______Learning disabilities class			______ Speech & language therapy
	______ Duration of placement			______ Duration of therapy
	______ Behavioral/emotional disorders class	______ Other (please specify)
	______ Duration of placement			______ Duration
			
Has the child ever been:  (If yes, please explain.)
	______ Suspended from school			______Number of expulsions
	______ Number of suspensions			______ Retained in grade
	______ Expelled from school				______ Number of retentions
			
Have any additional instructional modifications been attempted?  (If yes, please explain.)
			______ None
			______ Behavior modification program
			______ Daily/weekly report card
			______ Occupational Therapy
			______ Tutoring
			______ Other (please explain)

Does the child like school?	Most of the time ______	Sometimes ______	     Almost never _____

Does the child:
	Have problems with other children in class?					Yes _____     No _____
	Have problems making friends in school?					Yes _____     No _____
	Have problems getting along with teachers?					Yes _____     No _____
	Tend to get sick in the morning before school?				Yes _____     No _____

Describe the teacher’s current concerns about the child’s schoolwork or behavior:

What kind of grades has the child received in the past year?
A’s & B’s ______	B’s & C’s ______	  C’s & D’s ______	     D’s & F’s ______
or
Outstanding ____    Good ____    Satisfactory ____    Improvement needed ____    Unsatisfactory ____
or
Other grading system: 											

Are these grades a change from previous years?				Yes _____     No 	

In the past year, how much school has the child missed due to illness or injury?
Less than 2 weeks ____		2 to 4 weeks ____	5 to 8 weeks _____	     Over 8 weeks _____
Briefly describe the reasons if the child has missed a lot of school:

Does the child seem to have a “school phobia”?				Yes _____     No _____
If yes, explain: 												

SOCIAL HISTORY

How does the child get along with his/her brothers/sisters?		How easily does the child make friends?
		_____ Doesn’t have any					_____ Easier than average
		_____ Better than average					_____ Average
		_____ Average						_____ Worse than average
		_____ Worse than average					_____ Don’t know

			On the average, how long does your child keep friendships?
					_____ Less than 6 months
					_____ 6 months to 1 year
					_____ More than 1 year
					_____ Don’t know
FAMILY HISTORY

The child lives with:
_____ Biological parent(s) only		_____ Relatives			  _____ Foster parents
_____ Biological parent and other		_____ Adoptive parents		  _____ Institutional care
_____ Other placement 											

The family income is:
_____ under $10,000	      _____ $10,000 - $29,999        _____ $30,000 - $50,000       _____ over $50,000

What is the name of the child’s biological mother? 								
a.  Is she living?   Yes _____	No _____         If deceased, explain: 					
b.  Her age? 													
c.  What is her level of education? 										
d.  Her occupation? 												
e.  Does she live in the same house as the child?     Yes _____		No _____
f.  How often does she see the child? 									
g.  How involved is the mother in the child’s upbringing?   Very _____  Somewhat ____  Not at all _____
h.  Did the mother have a learning disability or other problems when she was in school?   Yes ___    No ___
      If yes, describe: 												

What is the name of the child’s biological father? 								
a.  Is he living?   Yes _____	No _____         If deceased, explain: 					
b.  His age? 													
c.  What is his level of education? 										
d.  His occupation? 												
e.  Does he live in the same house as the child?     Yes _____		No _____
f.   How often does he see the child? 									
g.  How involved is the father in the child’s upbringing?   Very _____  Somewhat _____	Not at all _	
h.  Did the father have a learning disability or other problems when he was in school?  Yes ___   No 	
     If yes, describe: 												

Please list the names, ages, and grade (or job) of the child’s brothers and sisters:
		       Name				         Age			  Grade or Job

														

														

Has anyone in the child’s biological family (including parents, grandparents, siblings, cousins, aunts & uncles) ever had any of the following:

					Which relative?		Describe the problem briefly
_____ Brain disease												

_____ Developmental delay											

_____ Epilepsy or seizures											

_____ Learning disability											

_____ Mental retardation											

_____ Neurologic disease											

_____ Psychological problems										

_____ Reading or spelling difficulties							     

_____ Speech or language problems									
_____ Other													

Which of the child’s biological relatives are left-handed?
Mother _____		Father _____		Sibling(s) _____	Grandparents _____	   No one _____

What languages are spoken in the home?		(List in order of the most frequent first.)
(1) 							(2) 							

How is the child disciplined? 											

List the child’s usual recreational activities and hobbies:

Have there been any major family stresses or changes in the past year (e.g., moving with change of school, divorce, significant illness, etc.)?				Yes _____		No _____
	If yes, please explain: 										

How much stress have these changes caused the child?	(circle one)
	None			Mild			Moderate			Severe

PREVIOUS EVALUATIONS

Which of these tests or procedures recently have been done?	Note any abnormal findings.

			Evaluation			    Check here if normal          Abnormal findings
_____ Blood work									    			
_____ Family physician or pediatrician office visit					    			
_____ Hearing testing								    			
_____ Lead level check								    			
_____ Lumbar puncture or spinal tap						    			
_____ Neurological examination or testing (CT scan, EEG)				    			
_____ Psychological or neuropsychological testing					    			
_____ School testing									    			
_____ Speech & language testing							    			
_____ Vision testing									    			
_____ X-rays										    			
_____ Other tests:

What are the names of the physician, psychologist, school authority, or other professionals we may contact who are most familiar with the child’s problems?

Name 								Name 						

Address 							Address 					

Phone 								Phone 						

Profession 							Profession 					

														
	       Parent or Guardian’s Signature						  Date