Neurofeedback Evaluation

Neurofeedback Evaluation

Adolescent (High School)

Client’s Name:
Today’s Date:
Age: / Date of Birth:
M or F (circle one)
Name of Client’s School:
Grade:
Handedness: Left or Right Handed or Mixed (circle one)

Has your child ever had issues, problems or concerns with any of the following sleep issues?

Difficulty falling asleep / Sleepwalking
Difficulty staying asleep / Severe and/or excessive nightmares
Difficulty waking up in the morning / Night terrors
Restless sleep / Other sleep problems

Please explain

Has your child ever had any of the following health concerns?

Allergies / Hearing problems
Asthma / Ringing in ears
Frequent illness / Vision problems
Fatigue / Heart problems
Chronic Pain / Skin problems

Please explain

Has your child ever had any of the following digestive, gastrointestinal, or endocrine problems?

Thyroid (high, low, or abnormal) / Intestinal Pain
Heat or cold sensitivity / Chronic constipation
Diabetes / Nausea or vomiting (unrelated to virus/flu)
Sugar sensitivity / PMS
Stomach pains

Please explain

Describe your child’s eating habits, including awareness of appetite and thirst.

Has your child ever had any of the following neurological concerns?

Headaches / Tremor or spasticity
Fainting / Physically over or under-active
Seizures / Accident prone
Coordination / Motor or vocal tics

Please explain

How does your child react to each of the following: (example: does coffee or caffeine help your child focus? Make him or her hyperactive, silly, or tired? If your child has no experience with a substance (e.g. diet pills, alcohol, or other drugs), write N/A.)

Coffee or Caffeine

Alcohol

Cigarettes

Diet or other drug use

Have you ever been concerned about any of the following emotional or behavioral issues regarding your child?

Mood swings / Tantrums
Anxiety or Worry / Aggressive or violent behavior
Depression / Manic symptoms
Fears or phobias / Obsessive-Compulsive symptoms
Panic attacks / Eating disorders
Irritability / Addictions
Anger / Risk-taking behavior

Please explain

Has your child ever had any problems with any of the following attention or organizational issues?

Short attention span / Impulsivity
Distractibility / Difficulty organizing

Please explain

Please answer the following questions about your child’s school behavior and performance.

What are your child’s favorite school subjects?

What are your child’s least favorite subjects?

Describe your child’s abilities concerning verbal expression and vocabulary.

Describe your child’s interest, abilities, and performance in each of the following areas:

Reading

Math

Writing

Penmanship

Art

Spatial Skills

Memory

Homework

What do teacher’s usually offer praise to your child for? What, if any, complaints do teachers have?

At home, what concerns do you have about interactions with:

Parents

Siblings

During pregnancy and childbirth, did your child experience or have difficulties with any of the following?

Prenatal stress or injury / Premature or late birth
Prenatal drug exposure / Medical problems shortly after birth
Difficult labor / Adoption, at what age?
Difficult birth

Please explain

During early growth and development, did your child experience or have difficulties with any of the following?

Colic / Motor development
Sleep problems / Language development
Eating problems / Chronic ear infections
Activity level / Allergies
Emotional attachment to care givers / Asthma
Emotional development

Please explain

Has your child ever experienced any of the following physical traumas?

Head injury / Drug overdose
Accidents / Poisoning
High fever / Anoxia (lack of oxygen)
Serious illness / Stroke
Central Nervous System Infection

Please explain

Has your child ever experience any of the following psychological traumas?

Abuse or Neglect / Death in family
Excessive or extreme family stress / Illness in family
Excessive school or job stress

What medications is your child currently taking now? What medications has your child taken previously for the same or similar conditions?

Medication / For Condition / Dosage / Dates (Month/Year)
Start: / Stop:
Start: / Stop:
Start: / Stop:
Start: / Stop:

What relevant medical treatment has your child received?

Procedure / For Condition / Description / Dates (Month/Year)

What psychological therapy has your child received?

Therapy / For Condition / Name of Therapist / Dates (Month/Year)

Has your child received any other relevant therapy?

Therapy / For Condition / Name of Therapist / Dates (Month/Year)

Please indicate if anyone in the child’s family, including parents, siblings, maternal and paternal, aunts, uncles, and grandparents, has experienced problems with any of the following:

Symptom / Yes / No / Relationship to child
Asthma
AutoimmuneDisorders: Type I Diabetes, RheumatoidArthritis (RA), Lupus, MS, etc.
Thyroid Disorder
Migraines
Sleep Problems
Depression
Manic Depression or Bipolar Disorder
Anxiety
Phobias
Panic Attacks
Motor or Vocal Tics
Seizures
Eating Disorders or Obesity
Addictions
Obsessive Compulsive Symptoms
Speech Problems
Attention Problems
Hyperactivity
Learning Problems
Conduct Problems or Criminal Behavior
Autistic Spectrum Disorders
Schizophrenia

Rate symptoms that apply to your child’s situation 1-10, with 1 being a slight problem and 10 being an extreme problem. If it does not apply, please leave it blank.

1. SLEEP / OFFICE USE ONLY
Bruxism (teeth grinding) / Difficulty falling asleep
Difficulty staying asleep / Difficulty waking up / Sx 1
Disregulated sleep cycle / Narcolepsy
Night sweats / Night terrors / Sx 2
Nightmares or vivid dreams / Nocturnal enuresis
Periodic leg movements / Restless leg / Sx 3
Restless sleep / Sleep Apnea
Sleep walking / Snoring / Sx 4
Talking during sleep
2. ATTENTION AND LEARNING / Sx 5
Difficulty completing tasks / Difficulty following directions
Difficulty making decisions / Difficulty organizing personal time or space / Sx 6
Difficulty remembering names / Difficulty shifting attention
Difficulty shifting tasks / Difficulty thinking clearly / Sx 7
Difficulty understanding conversations / Distractibility
Lack of alertness / Lacking common sense
Messy handwriting / Not listening
Poor concentration / Poor drawing ability
Poor math skills / Poor short-term memory
Poor sustained attention / Poor verbal expression
Poor vocabulary / Poor word finding
Difficulty reading / Slow thinking or processing
Unmotivated
3. SENSORY
Auditory hypersensivity / Chemical sensitivities
Motion sickness / Poor body awareness
Sensory deficits / Tactile hypersensitivity
Tinnitus (ringing in the ears) / Vertigo
Visual deficits / Visual hypersensitivity
4. BEHAVIOR
Addictive behaviors / Aggressive behaviors
Anorexia / Autistic Stemming
Binging and Purging / Class clown
Compulsive behaviors / Compulsive eating
Crying / Excessive talking
Hyperactivity / Impulsivity
Inflexibility / Lack of appetite awareness
Lack of sense of humor / Lack of social interest
Manipulative behavior / Motor or vocal tics
Nail biting / Oppositional or defiant behavior
Poor eye contact / Poor grooming
Poor social or emotional reciprocity / Poor empathy
Poor speech articulation / Stuttering
Self-injurious behavior / Picking at skin or scabs
Pulling out hair or rubbing bald spots / Pulling out fingernails, eyelashes or eyebrows
5. EMOTIONAL
Agitation / Anger
Anxiety or excessive worry / Depression
Difficult to soothe / Dissociative episodes
Easily embarrassed / Emotionally reactive
Fears / Feelings of unreality
Flashbacks of trauma / Impatience
Irritability / Lack of emotional awareness
Lack of pleasure / Lack of social awareness
Low self-esteem / Manic behavior or episodes
Mood swings / Obsessive negative thoughts
Obsessive worry / Panic attacks
Paranoia / Suicidal thoughts
6. PHYSICAL
Allergies / Asthma
Chronic constipation / Clumsiness
Difficulty walking or moving / Difficulty working
Effort fatigue / Encopresis
Fatigue / Heart palpitations
High blood pressure / Hot flashes
Immune deficiency / Irritable bowel
Low muscle tone / Muscle tension
Muscle twitches / Muscle weakness
Nausea / Poor fine motor coordination
Poor balance / Poor gross motor coordination
Reflux / Seizures
Skin Rashes / Spasticity
Stress incontinence / Sugar craving and reactivity
Sweating / Tachycardia
Tremor / Urge incontinence
7. PAIN
Abdominal pain / Chronic aching pain
Chronic nerve pain / Fibromyalgia
TMJ or jaw pain / Joint pain
Migraine headaches / Muscle pain
Muscle tension headaches / Sciatica
Sinus headaches / Stomach aches
Trigeminal neuralgia