PATIENT NAME: DATE: QUESTIONNAIRE COMPLETED BY: Confuses the details of games and stories

Transcription

1 PATIENT NAME: DATE: QUESTIONNAIRE COMPLETED BY: Check the choice that most closely fits your child. Please do not omit any questions. DEGREE OF ACTIVITY NEVER RARELY SOMETIMES OFTEN 1. ATTENTION Confuses the details of games and stories Needs a calm, quiet atmosphere in order to work Or concentrate Doesn t finish what he/she starts (book, puzzle) Hears, but doesn t seem to listen Has difficulty concentrating or paying attention unless in A one on one structured situation Asks to have things repeated Easily distracted Has difficulty concentrating on schoolwork or other Tasks requiring sustained attention Has difficulty sticking to a play activity Can work well only on things which he/she enjoys Doing or thinking about Given three directions such as: 1. take your shoes to your room 2. get your coat 3. and come out to the car Would this be accomplished the first time? ACTIVITY Is always on the go Acts as if driven by a motor Fidgets or squirms Has difficulty sitting still or fidgets excessively Does things in a loud or noisy way Must always be doing something, or he/she Becomes fidgety

2 3. IMPULSIVE Has difficulty staying seated Disrupts other children Has trouble waiting his/her turn in games or group Situations Talks excessively Calls out in class; makes noises in class Is extremely excitable Often acts before thinking Shifts excessively from one activity to another Has difficulty organizing work Needs a lot of supervision Sounds, textures or brightness are bothersome Clothing tags must be removed from clothing ANXIETY Difficulty with separation from parents Fear of humiliation or embarrassment in social or Performance setting Fear of a specific object or situation Panic-like symptoms Is very fearful of new situations, people, places Tolerates change poorly

3 5. OVERFOCUSED Focuses on thoughts or objects to an excess Attempts to distract or remove object of focus Are met with strong objections Gets stuck repeating a behavior to an excess (washing, Counting, checking) Prefers neat and orderly household; upset when things Are out of order Prefers a constant routine; upset by changes in routine Remains angry about the same thing for longer than 30 minutes SOCIAL PROBLEM Must do things my way ; can t be taught how to do things Cheats; has to be the winner Complains of unfair treatment; everyone is against him/her Has had friendships with children in his/her age group At least 6 months Extends him/herself for others even when no Immediate advantage is likely Angers easily and quickly Actively defies or refuses to comply Resentful, spiteful, or vindictive

4 7. CONDUCT-AGRESSION Swears, uses vulgar language Lying to other than family members over a period Of at least 6 months Serious lying in and out of the home over a period of At least 6 months Stealing not involving confrontation with a victim over A period of at least 6 months Was violent and aggressive, assaulted others, got into Fights lasting over a period of at least 6 months Thefts outside the home involving confrontation with a Victim over a period of at least 6 months Ran away from home overnight during a period of at Least 6 months Violation of important rules at home or at school (drugs Truancy) for a period of at least 6 months DEPRESSION Is pessimistic, thinks things will go badly Has a poor self-image; feels worthless Wants friends but is rejected or avoided by other Children Feelings are hurt easily by children Feels an inner sense of guilt or remorse when acts Poorly Avoids blaming or informing on companions Shares concern for the welfare of friends or Companions Depressed, sad, down in the dumps Cries for the slightest reason

5 9. LANGUAGE Between ages 2 ½ and 5 years Hesitated or stopped in mid-sentence Seemed to understand, but had trouble getting the Words out Had difficulty finding the right word Confused words that sound alike such as hem/hen Confused the order of words such as Ball, I hit Unable to tell about what happened to him/her, such As about his/her day Single words by age Communicative phrases by age EARLY STATE First 6 months of life Had difficulty falling asleep Awakened frequently Spit up frequently Medication was prescribed to soothe baby Easily upset by sights and sounds Unresponsive to sights and sounds Attentive to sights and sounds Disliked being held

6 11. SENSORY INTEGRATION Sounds, textures or brightness are bothersome Clothing tags must be removed from clothing Can t tolerate a noisy busy place, will go wild in a Crowd Has difficulty sharing enjoyment, interests or Achievements Has difficulty understanding humor Has difficulty making/sustaining eye contact Has difficulty interpreting facial expressions or Body language Has repetitious muscle motor mannerisms i.e. hand flapping or twisting

7 How difficult or easy were the following activities to learn? Not to Pretty Easy Difficult Difficult Difficult 12. Fine Motor-Early Eating with utensils Getting dressed by him/herself Doing buttons and zippers Tying his/her shoes Printing letters of the alphabet Fine handwork in general, such as puzzles, models Academics-Early Telling time Counting money Recognizing numbers Recognizing letters SLEEP Moves about excessively during sleep Snores loudly and restlessly Does not seem rested on awakening Chokes, coughs, or stops breathing during sleep Rocking in crib or bed