Neuropsychology Intake Form

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Neuropsychology Intake Form Name: Today s Date: _ Date of Birth: Age: Home Address: _ City ST Zip Home Phone: Name of person filling out this questionnaire: _ Person who referred you: _ May we thank this person? Y N Referral Information Problem Statement: Describe your personal strengths: Describe some of your personal weaknesses: What do you hope to learn as a result of the evaluation? 1

Pregnancy and Birth History Age of mother at delivery: Age of father at delivery: Known health problems of mother during pregnancy (circle all that apply) Toxemia Hypertension Gestational Diabetes Trauma Fever Allergies Smoking Alcohol Use Drug Use Antibiotics Depression Anxiety Blood Incompatibility Injury Accidents Emotional Abuse Physical Abuse Sexual Abuse Spouses abuse: Other: Mental Illness Sexually Trans. Disease Other: Other: Please explain: List any medications, tobacco use, alcohol use, or drugs taken by mother during pregnancy: Delivery: Vaginal Cesarean If Cesarean, reason? Full Term Premature Weeks Gestation Time spent in labor hours Birth Weight lbs. oz Circle any birth complications that apply: Feet first Cord around neck Meconium staining Lacking oxygen Jaundice Not breathing Other: Other: Explain: Apgar scores: How old were you at discharge from the hospital after birth? Please explain any medical problems after discharge and interventions: Any problem in first few months? _ 2

Developmental History Speech/Language: First language Language spoken in the home Age spoke first word Age put 2-3 words together (short sentences) Circle all that apply to you as a child or currently: Speech delays Stuttering Hard to Understand Late Drooling Poor Sucking Poor Chewing Articulation Problems Slow to learn alphabet Slow to learn colors Slow to learn counting Other: Other: Please list any speech therapy services you have received Motor: Age sat alone: crawled: _stood alone:_ walked alone: Were you slow to develop motor skills or awkward compared to siblings/friends (e.g., running, skipping, climbing, biking, playing ball?) Y or N Explain: Handedness: Right Left Ambidextrous (both) Family history of left-handedness (list relatives)? Please list any physical or occupational therapy services your child has received 3

Medical History Has your vision been checked? Y or N Any problems: Has your hearing been checked? Y or N Any problems: CT or MRI Date obtained? _ Results: EEG Date obtained? Results: Other tests and results: List serious illnesses/injuries/hospitalizations/surgeries Date Incident (explain) Circle all that apply to you in terms of your medical history: Failure-to-thrive Febrile seizures Epilepsy Staring spells Head injuries Meningitis Encephalitis Asthma Allergies Diabetes Loss of Consciousness Abdominal pains Vomiting Headaches Ear infections Sleep difficulties Sleep walking or talking Eating difficulties Eating disorder Facial or other Tics Repetitive movements Impulsivity Temper tantrums Nail biting Clumsiness Head banging Self-injurious behavior Physical injuries Lead poisoning/toxic ingestion Other: Other: Other: Other: Please explain the age of occurrence, relevant information, and interventions of any conditions circled above: Current medications and reasons: _ Current physician and their address: 4

Psychological and Treatment History (Circle all that apply) Learning Difficulties Mental Illness Neurological Illness Seizures Psychiatric Disorder Schizophrenia Depression Bipolar Disorder Anxiety Suicide Alcoholism Drug Abuse Legal Problems Arrests Obsessive-Compulsive Personality Disorder Disorder Other: Other: Other: Other: Please explain: Is there a family history of mental illness? Social/Emotional History Have you experienced (circle all that apply): death of a loved one separation from a loved one emotional trauma sexual abuse family conflict marital conflict physical abuse emotional abuse Please explain Please list current and past psychologists, social workers, psychiatrists, counselors, outpatient and inpatient treatment, cognitive evaluations, neuropsychological evaluations, psychological testing, etc. Name/ Occupation Dates Seen For What? Describe Progress Please add any additional information you would like us to know: 5

Social Behavior Please explain any pertinent issues regarding your social behavior: Does your make and maintain friendships? Y N Does you have any close friendships? Y N Please explain: Have you ever had particular sensitivities (i.e., food, tags on clothing, etc.)? 6

Educational History Current school and address: _ Grade: Placement: Gifted Regular Special Education (IEP) Other Any grades that were skipped? repeated? Teachers reported problems in: Reading Spelling Arithmetic Writing Attention Behavior Social Adjustment Hyperactivity Impulsivity Easily Distracted Other: Other: Please describe the above noted problem(s) _ Grade: Academic problems? (Please describe) Have you ever been evaluated for special education? Y or N (If yes please provide a copy of the evaluation) _ 7

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