Personal and Family History Questionnaire

PERSONAL AND FAMILY HISTORY QUESTIONNAIRE

PEDIATRIC & ADOLESCENT NEUROPSYCHOLOGY

MONTANA NEUROBEHAVIORAL SPECIALISTS

ROBERT A. VELIN, PH.D.

Date this form was completed: ______

Person/Title completing this form: ______

IDENTIFYING INFORMATION

Child’s First Name: ______

Child’s Last Name: ______

Date of Birth: ______

Gender: ______

Race: (Check below)

___ Caucasian

___ African American

___ Native American

___ Asian

___ Hispanic

___ Other ______

Handedness: (Check below)

___ Right

___ Left

___ Ambidextrous

___ Not yet established

Name of School: ______

Current School Grade: ______

Parents’ Names: ______

Parents’ Address: ______

______

Home phone: ______

Work phone: ______

Cell phone: ______

CURRENT CONCERNS

Yes No Date first Noticed

Academic Skills ______

Alcohol Abuse ______

Anxiety ______

Apathy ______

Attention ______

Defiance/Oppositional ______

Depression ______

Diet/Nutrition ______

Drug Abuse ______

Family Relationships ______

Fine Motor Skills ______

Gross Motor Skills ______

Hurting Others ______

Hurting Self ______

Impulsivity ______

Intellectual Ability ______

Irritability/Anger ______

Language Skills ______

Lying ______

Mood Lability ______

Obsession ______

Organizational Skills ______

Hyperactivity ______

Passivity ______

Physical Aggression ______

Physical Complaints ______

Repetitive Movements ______

Repetitive Sounds ______

Sadness ______

Self-Stimulatory Behavior ______

Sexual Issues ______

Sleep Patterns ______

Social Difficulties ______

Special Fears ______

Stealing ______

Tantrums ______

Toileting/Soiling ______

Trauma Experiences ______

Verbal Aggression ______

Withdrawal ______

Other Concerns ______

______

Prioritize and describe the specific problems that you would most like addressed by this evaluation: ______

______

Is your child aware of the problems(s) and your concerns? Yes___ No___

If yes, what have they said to you about the problems?

______

What strategies have been implemented to address these problems?

______Verbal Reprimands

______Time-out (isolation)

______Removal of Privileges

______Rewards

______Physical Punishment

______Acquiescence to Child

______Avoidance of Child

______Other______

Have you talked with your child about this evaluation? Yes___ No___

If yes, what was your child’s reaction?

______

FAMILY HISTORY INFORMATION

Who lives in the household in which the child usually lives?

___ Biological Mother

___ Biological Father

___ Stepmother

___ Stepfather

___ Adoptive Mother

___ Adoptive Father

___ Sisters (give names and ages)______

___ Brothers (give names and ages)______

___ Stepsisters (give names and ages)______

___ Stepbrothers (give names and ages)______

___ Grandparents

___ Aunt or Uncle (give names and ages)______

___ Significant Other

___ Foster Parents

___ Foster Siblings (give names and ages)______

___ Other (please describe)______

If your child has been placed out of the home, when was the last time he/she lived at home?

Give month and year______

For what reason was child placed out of the home for first time? ______

______

Birth Parents Information

Birth Mother: ______

Current Age: ______Occupation: ______

Education (Highest grade completed): ______

Birth Father: ______

Current Age: ______Occupation: ______

Education (Highest grade completed): ______

Marital Status of Birth Parents:

___ Married

___ Married but separated (give date of separation):______

___ Married but divorced (give date of divorce):______

___ Never married

If never married, separated, or divorced, does the child have contact with both parents?______

Name of Contact:______

Frequency: ______

Mood of visits: ______

Adoptive Parents Information

Adoptive Mother: ______

Current Age: ______Occupation: ______

Education (Highest grade completed): ______

Adoptive Father: ______

Current Age: ______Occupation: ______

Education (Highest grade completed): ______

Marital Status of Adoptive Parents.

___ Married

___ Married but separated (give date of separation):______

___ Married but divorced (give date of divorce):______

___ Never married

If never married, separated, or divorced, does the child have contact with both adoptive parents?______

Name of Contact:______

Frequency: ______

Mood of visits: ______

Does the child know he/she is adopted? Yes___ No___

Does the child ask questions about the birth parents? Yes ___ No___

Please describe the questions and your response: ______

______

Foster Parent Information

When was the child placed in your home? ______

Has the child had previous foster placements? Yes ____ No _____ If yes, please describe.

______

Does the child have contact with one or both birth parents? Yes ___ No ___ If yes, please describe the nature and time of these visits:______

______

DEVELOPMENTAL HISTORY INFORMATION

Pregnancy

Length of Pregnancy: ______

Complications: Yes No Comments

Anemia ______

Bleeding ______

Consume Alcohol ______

Drug Use (e.g., Marijuana) ______

Heart Disease ______

High Blood Pressure ______

Hospitalization ______

Injury/Accident ______

Operation ______

Prescribed Medications ______

Rh Factor Incompatibility ______

Smoking Cigarettes ______

Threatened Miscarriage ______

Toxemia/Eclampsia ______

Labor and Delivery

Please mark any of the following that describe labor and delivery:

___ Labor induced

___ Delivered by Cesarean Section

___ Deliver aided by instruments (circle: foreceps, vacuum, other)

___ More than one baby born

___ Child blue at birth

___ Child yellow (jaundiced) at birth. Treatment?______

___ Child bruised at birth. Where on body?______

___ Child breathe spontaneously.

___ Oxygen administered

___ Child placed in incubator

___ Apgar score: 1 minute______; 5 minutes______

Birth weight______

Length of hospital stay: ______

Any other delivery/postnatal complications: ______

______

Were any problems with the child identified at birth? ______

______

Did the child’s mother experience Postnatal Depression? ______

Neonatal Period

Please mark any of the following problems that occurred with your child:

___ Apnea (Child stopped breathing)

___ Colic

___ Congenital anomalies (physical abnormalities the child was born with)

___ Failure to thrive, feeding failure

___ Infections

___ Seizures

___ Sleep difficulties (sleepwalking, falling asleep, sustaining sleep)

___ Sucking, swallowing, or chewing difficulties

___ Other ______

Were there concerns regarding the baby’s responsiveness?______

______

Was the baby easy or difficult to sooth?______

Was your baby floppy, tense, or otherwise unusual in the way he/she held his/her body?

______

Early Developmental Milestones

Indicate your child’s approximate age in months for the following milestones:

Sat alone without support ______

Crawl ______

Walked without support ______

Said single words ______

Put 2-3 words together ______

Bladder trained during the day ______

Bowel trained ______

Bladder trained at night ______

For the following questions, please score according:

1 if less often than other children

2 if about the same as other children

3 if more often than other children

During the first three years of life, in comparison to other children of the same age, did your child:

___ Cry

___ Have temper tantrums

___ Show fear of new places and/or faces

___ Seem distractible

___ Seem unresponsive to discipline

___ Engage in self hurting or injuring behavior

___ Act irritably

___ Act aggressively

___ Enjoy being held

___ Seem overly active

___ Explore surroundings

___ Listened to stories

___ Enjoyed running and climbing on objects

___ Enjoyed playing with Legos and puzzles

___ Showed emotional responsiveness

___ Demonstrating coordination

Ongoing Areas of Child Development

Please comment on your child’s ability in the following areas:

Hearing: ______

Vision: ______

Gross motor coordination: ______

Fine motor coordination: ______

Speech articulation: ______

Difficulty with textures such as certain foods or clothing (e.g., tags): ______

______

MEDICAL HISTORY INFORMATION (Use reverse side if more room is needed)

Illness/Injury: Yes No Comments

Allergies ______

Asthma ______

Cerebral Palsy ______

Clumsiness ______

Diabetes ______

Eating Difficulties ______

Eating Disorder ______

Frequent ear infections ______

Ear tubes place (include age) ______

Gastrointestinal problems ______

Head banging ______

Head injury ______

Headaches ______

High fever (104+) ______

High lead level ______

Hospitalization (and date) ______

Impulsivity ______

Loss of consciousness ______

Meningitis/encephalitis ______

Oxygen deprivation (Anoxia) ______

Repetitive movements

(e.g., hand flapping) ______

Seizures ______

Self injurious behavior ______

Sleep difficulties ______

Staring spells ______

Surgeries (provide dates) ______

Tic/twitching ______

Other ______

List all medications that your child currently takes on a regular basis (precription drugs and over-the-counter medication such as aspirin and cough syrup, etc.)

Date Medication Dose Prescribed by

______

Has your child received medication in the past for learning or behavioral problems?

Date Medication Dose Prescribed by

______

Has the onset of puberty appeared to cause any difficulties for your child? Yes_____ No ______

If yes, explain:______

______

FAMILY HISTORY

Have any blood relatives had any of the following? Indicate family member and whether from maternal (M) or paternal (P) side of the family:

Medical/Psychiatric History Yes No Family Member(s) M/P

ADD/ADHD ______

Alzheimer’s Disease ______

Anxiety Disorder ______

Autism/Asperger’s Disorder ______

Bipolar/Manic Depression ______

Cancer ______

Chronic headache ______

Depression ______

Diabetes ______

Drug/alcohol abuse ______

Epilepsy/Seizures ______

Heart trouble ______

High blood pressure ______

Hyperactivity ______

Learning difficulties (specify) ______

Migraines ______

Nervous breakdown ______

Obsessive-Compulsive Disorder ______

Personality Disorder ______

Schizophrenia/Psychosis ______

Sleep disorder/apnea ______

Speech problems ______

Stroke ______

Thyroid problems ______

Other ______

SOCIAL HISTORY

Does your child get along with other children? ______Adults? ______

Does your child have friends?______

Is your child able to keep friends? ______

Does you child understand gestures?______Have a good sense of humor?______

Understand social cues well (e.g., knows when others are angry, are in discomfort)? ______

Elaborate your concerns regarding your child’s social skills: ______

______

Has your child ever experienced or witnessed:

_____ Domestic violence

_____ Foster home placement

_____ History of arrests

_____ History of frequent moves

_____ Illness/death of family member or pet

_____ Legal concerns

_____ Multiple care givers

_____ Natural disaster, accident, or serious injury

_____ Parent hospitalizations

_____ Re-marriage

_____ Separation or divorce

If yes to any of the above, elaborate. Does your child experience any nightmares, flashbacks, or problems sleeping related to these issues? ______

______

Physical/Emotional/Sexual Abuse:

Has your child been the victim of physical, emotional, or sexual abuse? Yes___ No ___

If yes, please describe giving dates, names and with whom you have previously shared this information.______

______

EDUCATIONAL HISTORY

Please list all school/daycare centers and dates of attendance for your child.

School Dates Any Problems?

______

Is truancy a problem? ______

Number and reasons for suspensions______

______

Number and reasons for expulsions______

______

Briefly summarize your child’s current academic grades: ______

______

Have teachers expressed concerns about your child’s learning? Yes___ No___ If yes, explain:

Year Grade Subject Concern

______

Have teachers expressed concern about your child’s behavior? Yes ___ No___ If yes, explain:

Year Grade Subject Concern

______

Have teachers expressed concerns about your child’s relationships with other children? Yes__ No__

If yes, elaborate:

Year Grade Subject Concern

______

What are your child’s best academic subjects?______

What are your child’s most difficult subjects?______

Does your child experience any of the following problems in school/home?

______Expresses fears

______Daydreams

______Loses things

______Has trouble finishing what he/she starts

______Fails to follow directions

______Forgets to do routine activities

______Has mood swings”

______predictable?

______unpredictable?

______Has trouble sitting still

______Tells lies

______Is unhappy

______Verbalizes low self-esteem (“I can’t do anything right”)

______Has no interests: Always complains of being bored

______Noncompliant with adult requests

______Overactive, always on the go

______Is fascinated with fire

______Seems clumsy

______Stutters

______Is verbally aggressive

______Is physically aggressive

______Has trouble making or keeping friends

______Seems unaffected by discipline

______Steals

______Lies

______Cheats

______Harms animals

______Has eating problems

______Does not like to change activities

______Seems lethargic

______Reports hearing things that other people do not hear

______Reports seeing things that others do not see

List your child’s strengths and interests: ______

______

Has your child repeated any grades? Yes ___ No ___ If yes, why was the grade repeated?

Has your child received any Special Education services? Yes ___ No ___

If yes, please list services, for example: Chapter 1 or Title 1; Special Education; 504 Plan; Individual Educational Plan (IEP); Speech Language Therapy (S/LT); Occupational Therapy (OT); or Physical Therapy (PT).

Date Grade Service

______

Approximate amount of time mainstreamed. ______

Previous Consultations/Evaluations: (Use reverse side if more room is needed)

(Include school district evaluations)

Yes No Dates Diagnosis/Results

Hearing ______

Vision ______

Neurologist ______

Psychologist ______

Social Worker ______

Speech/Lang ______

Educational ______

Occupational Therapy ______

Physical Therapy ______

Other ______

Please indicate if any of the above evaluations/professionals were helpful. ______

______

If there is any other information you would like to convey, please do so here: ______

______

Do you wish to speak with the doctor alone to discuss any issues regarding your child?

Yes___ No ___