Cogmed Questionnaire Date: / / Student s Name: D.O.B.: / / Grade: Gender: M F School: Caregiver Information: Names: Address: City: State: Zip: With whom does the child reside? Home Phone: Work Phone: Cell Phone: Email: May we contact you: May we leave a message: At home? Yes No At home? Yes No At work? Yes No At work? Yes No By cell? Yes No On cell? Yes No Via email? Yes No How did you hear about Cogmed Working Memory Training? Page 1 of 6
One of the benefits of Cogmed Working Memory Training is that the training can be completed at home or in another appropriate, comfortable environment. However in order to get the most out of the training, a computer and training environment that meets the required specifications is required. The following questions are intended to gather information that pertains to those specifications: What type of computer will the student have access to in order PC Mac to complete the training? If a PC, is Microsoft Windows XP, Vista, or 2007 currently installed? yes no If a Mac, would you be willing to install Boot Camp on your computer yes no in order to run Windows? Do you have internet access in your home? yes no Does your computer have a well functioning mouse? yes no (using an external mouse rather than the track pad is recommended) In order to see the best results, Cogmed training sessions should take place for 30-45 minutes (including breaks), five days a week, for five weeks. Can this time be set aside by the student? yes no Training has been shown to be most effective when an adult commits to serving as a training aid, sitting beside and monitoring the student s training at least initially. Who would be able to serve as a supportive training aide, committing to be present at all training sessions? Optimal results are achieved when the training environment is quiet and free from unnecessary distractions. Is the training aid able to create a good training environment? yes no Background Information: The following questions are intended to gather information in order to determine whether the student will likely benefit from Cogmed training How would you describe the student (interests, strengths, qualities, etc.)? Page 2 of 6
What are areas of difficulty for the student? In what types of situations are things difficult for the student? For how long have these difficulties been present? Testing/Diagnostic History: Has the student undergone any previous psychological, neuropsychological, yes no educational, etc. testing? If yes, please list testing dates, type of testing, and the results as you understand them: Date Type of testing/ Results Tests completed Has the student ever participated in intelligence testing? yes no If yes, please list testing dates and the results as you understand them: Date Results Was working memory assessed? yes no If yes, what were the results as you understand them? Does the student have any learning or psychological diagnoses? yes no If yes, please identify and include age of initial diagnosis: Diagnosis Age of initial diagnosis Page 3 of 6
Is the student taking any type of medicine? yes no If yes, please identify and include dosage and when medication was first prescribed: Medication Dosage First prescribed Academic History How is the student performing academically in school? What are his/her best subjects? In which subjects does he/she struggle the most? How are the student s social relationships? Does the student receive special education services? yes no If yes, please describe: The following questions pertain to areas that could possibly interfere with successful training: Has the student ever had a seizure? yes no If yes, are seizures or problems triggered by TV or computer games? yes no Has the student ever demonstrated motor or vocal tics? yes no If yes, please describe: Page 4 of 6
Does the student have any difficulties with If yes, please explain Sleep yes no Appetite yes no Headaches yes no Pain yes no Stress yes no Hearing yes no Vision yes no Has the student had periods of depression? yes no If yes, when did the symptoms begin? For how long did the symptoms last? How would you rate the severity of the depression? What is the current state of symptoms? Has the student had periods of significant fears or anxiety? yes no If yes, when and in what context did the symptoms begin? For how long did the symptoms last? How would you rate the severity of the anxiety? What is the current state of symptoms? How does the student respond to authority and limit setting? How does the student express disagreement or unwillingness to cooperate/participate? Page 5 of 6
Behavioral Rating Scale Filled out by: Relationship: For the following statements, please choose to what extent each statement applies to the student s behavior over the past week. Does not apply at all Applies to a slight extent Applies fairly closely Applies very much 1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities. 2. Often has trouble keeping attention on tasks or play activities. 3. Often does not seem to listen when spoken to directly. 4. Often does not follow 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 trouble organizing activities. 6. Often avoids, dislikes, or doesn t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework). 7. Often loses things needed for tasks and activities (e.g., toys, school assignments, pencils, books, or tools). 8. Is often easily distracted. 9. Is often forgetful in daily activities. 10. Often fidgets with hands or feet or squirms in seat. 11. Often gets up from seat when remaining in seat is expected. 12. Often runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless). 13. Often has trouble playing or enjoying leisure activities quietly. 14. Is often on the go or often acts as if driven by a motor. 15. Talks excessively. 16. Often blurts out answers before questions have been finished. 17. Often has trouble waiting for his/her turn. 18. Often interrupts or intrudes on others (e.g., butts into conversations or games). Page 6 of 6