Child Neuropsychological Form

Patient Information

Patient's Full Name:

Date:

Parent's Full Name:

Address:

City:

State:

Zipcode:

Email (Mother):

Email (Father):

Phone (Mother):

Phone (Father):

Pediatrician Full Name:

Practice Address:

Age:

Birth Date:

Sex:

Male Female Other

Grade:

Ethnic/Racial Background:

Primary Language:

Secondary Language:

Hand used for writing:

Right Left

Current problem areas/areas of concern:

Early History

Adopted:

Yes No

Duration of Pregnancy (in number of Weeks):

Smoking during pregnancy:

Yes No

Number of cigarettes per day:

Alcohol use during pregnancy:

Yes No

Amount per week:

Medications/drugs during pregnancy:

Type of Delivery

Vaginal Cesarean

(Explain if Cesarean):

Was labor spontaneous or induced?

Spontaneous Induced

Length of Labor:

Birth Weight:

Apgar Scores:

Post-Delivery

Cyanosis (turned blue)?

Yes No

Infection?

Yes No

(If yes, please specify):

Other illnesses or problems:

How many days was your child in the hospital nursery before being discharged home?

Difficulty with feeding?

Yes No

(If yes, please explain):

Developmental and Medical History

Developmental Milestones:

Age child crawled:

Age sat:

Age walked:

Did your child walk prior to 15 months?

Yes No

Age child said first word and talked in 2-3 word sentences:

Did your child speak first words (mama, dada) prior to 12 months?

Yes No

Did your child speak in 2-3 word sentences prior to 2 years old?

Yes No

Does your child use gestures to help communicate their wants and needs?

Yes No

Toilet Training:

Age child was toilet trained (day):

Age trained (night):

Do accidents still occur during the day?

Yes No

Do accidents still occur at night?

Yes No

Did your child receive Early Intervention (EI) services prior to age 3?

Yes No

Select which type of EI services received:

Speech Occupational Physical

Did your child receive interventions after age 3 through the school or privately?

Yes No

Select which type of intervention received:

Speech Occupational Physical

Has your child ever been tested for developmental disabilities? (e.g., cerebral palsy, specific learning disabilities, autism, ADHD, etc)

Yes No

Medical History

Please list past and current medical Conditions:

Has your child ever been hospitalized?

Yes No

If yes, describe:

Has your child ever suffered a serious injury to their head?

Yes No

If yes, describe:

Medications

Please note all medications taken at present, their dosage, and frequency given. Example: Depakote 100 mg. 2 tablets/ AM, 1.5 tablets/ afternoon, 4 tablets/ evening.

Name	Dosage/Amount	Frequency Given

Family History

Please check all that existed in close biological family members and provide details:

Physical/Psychiatric Problems	Who	Description
Neurological/Brain Condition
Learning Disability
Mental Retardation
ADHD
Alcohol/Drug dependency
Bipolar Disorder
Depression
Personality Disorder
Schizophrenia
Other Psychiatric Illness
Other Disease/ Disorder

Psychosocial History

People living in household with child:

Name	Age	Relationship to Child

Would you consider the current living situation stressful?

Yes No Maybe

What is your child's best attribute/characteristic?

What is your child's worst attribute/characteristic?

Describe any organizations, volunteering, hobbies, reading interests, or other leisure-time activities in which your child is currently engaged:

Psychological/Psychiatric Symptoms and Services

Has your child ever been under the care of a psychiatrist, psychologist, or counselor?

Yes No

If Yes, what were they seen for?

Are they currently under the care of:

Psychiatrist Psychologist/Counselor

Educational History

Name of School:

County:

Classroom Placement:

Regular Special

(Explain if Special):

Is child homeschooled?

Yes No

Since when?

Typical grades on report card:

Repeated grades?

Yes No

If yes, which grade(s)?

Skipped grades?

Yes No

If yes, which grade(s)?

Easiest subjects:

Difficult subjects:

IEP History?

Yes No

Section 504 Plan?

Yes No

During which grade was the IEP established?

Educational tutoring/remedial activities (if any):

Describe any school problems:

Substance Use History

Please check all the drugs your child/adolescent is using or has used in the past:

Substance	Presently Using	Used in the Past	Date
Alcohol
Tobacco
Caffeine
Amphetamines (including diet pills)
Barbiturates (downers)
Cocaine or crack
Hallucinogens/LSD
Inhalants (glue, spray cans, etc.)
Marijuana
Opiate narcotics
PCP (angel dust)
Other drugs:

Child Neuropsychological Form

Thank You!

Thank you for completing all the forms and uploading your documents!