Child s Name Age Grade. School School Phone # Previous Schools. Marital status Highest grade finished in school

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Alexander Samuel Hodges
6 years ago
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1 Initial Parent Questionnaire Which of our doctors is your child seeing for ADD? Child s Name Age Grade School School Phone # Principal Teacher Previous Schools Mother s name Occupation Marital status Highest grade finished in school Father s name Occupation Marital status Highest grade finished in school For each of the other children in the family, please give: Name Age Any medical or school problems In your own words, what is the reason for consulting us? When was this first noticed? Has your child been receiving special resources within the school?

2 Which special services? Has an Individual Education Plan been completed for your child? If more space is needed, please attach a separate page Family History Please check any of the following conditions that any close blood relative has had and note relationship to this child. Check here if child is adopted birth defects/malformations _ deafness/hearing loss seizures _ blindness death before age one year bedwetting mental retardation _ learning or school problems psychiatric problem headaches/migraine emotional problem/depression alcoholism drug addiction or dependency _ problems with the law/prison hyperactivity or attention deficit disorder tics/involuntary movements _ Pregnancy History To be completed by the patient s mother During your pregnancy with this child: 1. Did you experience any problems or complications? If so, please explain: 2. Did you use (please check if yes): cigarettes: how many per day? alcohol: how much? non-prescription medicines: which ones? prescription medicines: which ones? street drugs: which ones? 3. Were you exposed to any toxic substance? : which ones? Labor & Delivery

3 Please check any of the following that apply to the labor and delivery: premature by weeks caesarean section (elective/emergency) late by weeks forceps delivery labor induced breech position medications during labor fetal distress general anesthesia meconium (baby s stool) in amniotic fluid baby needed oxygen baby required resuscitation other problems: Birthweight length Apgar scores (if known) Nursery Stay and First Few Weeks Please check any of the following that apply to the baby s first couple of weeks: respiratory distress jaundice infection phototherapy (blue light treatment) feeding problems sleep problems illness surgery How long did the baby stay in the hospital nursery? _ Infancy Please check any of the following that apply to the patient s first year: feeding problems predictable schedule sleep problems cried a lot colic poor weight gain to us problems getting on a was never cuddly breast fed until months bottle fed until months was source of worry or concern Development Please indicate, as best you can remember, the age in months at which your child first did the following: rolled over sat without support crawled walked along furniture walked without support used spoon to feed self dressed without help could ride tricycle (right/left) spoke first word able to say 4 6 words spoke 2-3 word sentences could name 4 body parts toilet trained for daytime dry at night could name 4 colors developed handedness

4 Please check any of the following that apply to your child during the first few years of life: much more active than other children etc learned to do things very quickly felt dare-devil behavior had no fear discipline impulsive behavior follow rules tore up more toys than other children was aggressive towards other children attention timid or shy needs rigid daily schedule problems adapting to new situations gave up easily when frustrated sleep wandered away from home frequently more interested in things than people needed to touch or smell everything prone had problems separating from parents / her turn problems sharing toys, didn t care how others not affected by unable to learn or wanted to be left alone needed constant always testing limits many tantrums rocking or head banging problems with problems with eating problems with speech clumsiness / accident unable to wait for his Medical History Please give approximate dates and a brief explanation for any: Hospitalizations Surgeries Concussion, skull fracture or serious head injury Poison ingestion or overdose Serious illness

5 Serious accident Allergies to medicines Allergies to foods Other allergies Medicines taken regularly (include dosage) Please check any of the following that your child has or had: seizures kidney disease vision problems urine infections ear infections bedwetting hearing problems soiling heart murmur / heart disease hay fever / asthma / eczema hepatitis / liver disease anemia serious vomiting / diarrhea headaches constipation abdominal pain problems gaining weight problems growing tics / involuntary movements accident prone By Ned Owens M. Ed. Betty White Owens ADD BEHAVIOR RATING SCALE Name Age Grade Date Rate EVERY statement by placing the appropriate number which most fits the child s behavior in the box opposite the statement. 1 You have not noticed this behavior before 2 You have noticed this behavior to a slight degree 3 You have noticed this behavior to a considerable degree 4 You have noticed this behavior to a large degree 5 You have noticed this behavior to a very large degree 1. Fails to complete assigned tasks.. 2. Often acts before thinking 3. Runs or climbs a great deal...

6 4. Gets mad easily Is a poor reader.. 6. Doesn t seem to listen or pay attention Shifts excessively from one activity to another Has difficulty staying seated 9. Shows anger when told to do something Is a poor speller Poor concentration on difficult tasks Can t seem to organize school work Has difficulty sitting still; fidgets 14. Is easily frustrated 15. Does not follow verbal directions Doesn t stick to just one play activity (changes a lot). 17. Needs a lot of supervision Moves excessively during sleep or rocks in daytime Loses temper easily. 20. Handwriting is poor (may vary day to day). 21. Is distracted easily Interrupts or speaks out of turn 23. On the go much of the time. 24. Can t take testing. 25. Has difficulty in completing homework Rate EVERY statement by placing the appropriate number which most fits the child s behavior in the box opposite the statement. 1 You have not noticed this behavior before 2 You have noticed this behavior to a slight degree 3 You have noticed this behavior to a considerable degree 4 You have noticed this behavior to a large degree 5 You have noticed this behavior to a very large degree 26. Is afraid of many things Doesn t trust himself or downs himself Delights in others failures or getting in trouble. 29. Exhibits stubbornness. 30. Has I don t care attitude Worries about many things Seems satisfied with poor school work Pushes or shoves classmates 34. Resists being disciplined Is untruthful and may cheat at games Is easily embarrassed Doesn t compete with others Tries to boss other children. 39. Blames others for his mistakes or behavior. 40. Makes promises but doesn t keep them Appears nervous Is easily frustrated and gives up quickly Makes derogatory remarks about others. 44. Must have his own way Steals...

7 46. Appears tense Has little confidence 48. Plays tricks on others or teases Will not take suggestions Does not respect authority Rated by _ Relationship to child Social Skills Assessment Form Child s name Date Please check in the appropriate box the degree to which the following statements describe this child. Not Applicable Mild Moderate Severe Seems to be a social isolate, e.g., spends a large proportion of time in solitary activities, and may be judged independent and capable of taking care of him/herself. Seems to interact less with classmates and appears shy and timid. May be described as somewhat anxious with others. Seems to spend less time involved in activities with others due to a lack of social skills and / or appropriate social judgment. Seems to have fewer friends than most due to negative, bossy or annoying behaviors which turn off others. Seems to spend less time with classmates than most due to awkward or bizarre behavior. Disturbs other children: teases, provokes, fights, interrupts. Openly strikes back with angry behavior to teasing of other children. Argues and must have the last word in verbal exchanges. Displays physical aggression towards objects or persons. Uses coercive tactics to force the submission of peers; manipulates or threatens. Speaks to others in an impatient or cranky tone of voice. Says uncomplimentary or unpleasant things to other children, e.g., engages in name calling, ridicule, verbal derogation.

8 Please rate the following descriptors for this child by circling appropriate number after each item. Not Moderately Very Descriptive or Descriptive or Descriptive or not True True Very True Verbally responds when a child initiates Engages in long conversations Shares laughter with classmates Spontaneously contributes during group discussion Volunteers for show and tell Freely takes a leadership role Verbally initiates with a peer (s) Attention-Deficit Hyperactivity Disorder Diagnostic Criteria (DSM IV) Patient Name Date Completed By Please check symptoms that apply to this child: Inattention: 1. Often fails to give close attention to details or makes careless mistakes in school work, work or other activities. 2. Often has difficulty sustaining attention in tasks or play activities. 3. Often does not seem to listen when spoken to directly. 4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions). 5. Often has difficulty organizing tasks and activities. 6. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as school work or home work). 7. Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books or tools). 8. Is often easily distracted by extraneous stimuli. 9. Is often forgetful in daily activities. Hyperactivity Impulsivity: 1. Often fidgets with hands or feet or squirms in seat. 2. Often leaves seat in classroom or in other situations in which remaining seated is expected. 3. Often runs about or climbs excessively in situations where it is inappropriate (may be limited to subjective feelings of restlessness in older individuals). 4. Often has difficulty playing or engaging in leisure activities quietly. 5. Is often on the go or often acts if driven by a motor. 6. Often talks excessively.

9 7. Often blurts out answers before questions have been completed. 8. Often has difficulty awaiting turn. 9. Often interrupts or intrudes on others (e.g. butts into conversations or games). Symptoms (at least some) present before age 7 years. Some impaired function in at least two or more settings (e.g. school, work and home). Clear evidence of impairment in social, academic or occupational functioning. Differential diagnosis: rule out other psychologic, psychiatric, neurologic, or medical conditions that may better explain the symptoms. Page 8 REV 5-02

Francine Grevin, Psy.D. Licensed Clinical Psychologist PSY South Main Plaza, Suite 225 Telephone (925) CHILD HISTORY FORM

Francine Grevin, Psy.D. Licensed Clinical Psychologist PSY South Main Plaza, Suite 225 Telephone (925) CHILD HISTORY FORM Email: Dr.Grevin@eastbaypsychotherapyservices.com www.therapywalnutcreek.com CHILD HISTORY FORM Date Child s name Last First Child s birth date Gender Home address(es) Parent(s) names(s): Home phone (s)