Learning Differences and ADHD Testing Questionnaire Step 1 of 10 10% Please check this box if you are a parent filling out this form on behalf of your child: Yes, I am a parent filling out this form on behalf of my child. Examinee's name:(Required) First Last Today's date:(Required)Birth date:(Required)Grade (if applicable):Contact Information:Parent Name(s) (if applicable):(Required)Home Address:(Required) Street Address Address Line 2 City State ZIP / Postal Code Best Telephone Contact Number:(Required)Residents in examinee's home:(Required)Enter Your Name and 'Self' if completing for self. Click the + icon to add more.First NameLast NameRelationship to Examinee Add RemoveLanguage(s) spoken in the home:(Required)Institution/School:(Required) Background Information:What are the concerns or questions you would like addressed by this evaluation?(Required)What have you tried to do in the past to support the question(s)/concern(s)?(Required)Has this examinee already had testing/evaluations/IEP?(Required) Yes No Who did the testing?(Required)What were the results and conclusions?(Required) Prenatal HistoryWas this examinee the result of a planned pregnancy?(Required) Yes No Please check the boxes if any of the following occurred during the pregnancy:(Required) use of illicit drugs use of prescription medications use of alcohol tobacco toxemia high blood pressure anemia flu emotional problems poor health diabetes X-rays trauma/accidents other complications/problems none Birth HistoryBirth weight:(Required)Please enter a number from 1 to 25.# of pounds# of ounces(Required)Please enter a number from 1 to 15.# of ouncesHospital of birth (name, location):(Required)Type of birth:(Required) Vaginal C-Section After delivery, any difficulty with:(Required) Breathing Cord around neck Jaundice Poor suck/feeding Other None If "other," please explain:Number of days in the hospital for birth:(Required)Enter as a number (i.e. "2" days, instead of "two" days). Developmental HistoryDid the examinee have any significant health problems/injuries during the first year?(Required)if "Yes," please explain, if no enter "No."When did the examinee first: Answers should be in months.Sit up:(Required)# of monthsCrawl:(Required)# of monthsWalk:(Required)# of monthsTalk (single words):(Required)# of monthsTalk (sentence of at least 3 words):(Required)# of monthsToilet train:(Required)# of monthsDoes the examinee have a history of:(Required) Asthma High fevers Unusual illnesses PE (ear tubes) Recurring ear infections Hydrocephalus Meningitis Diabetes Scoliosis Allergies Other None If "other," please explain:Has the examinee ever been exposed to toxic substances (ingest lead paint, toxic chemicals, radiation treatments, etc.)?(Required) Yes No Has the examinee ever been hospitalized?(Required) Yes No Please explain:(Required)Has the examinee ever had a seizure?(Required) Yes No Please explain:(Required)Has the examinee ever had a concussion, loss of consciousness, or other significant head injury?(Required) Yes No Please explain:(Required) Current HealthDoes the examinee have any color blindness?(Required) Yes No Does the examinee need to wear eyeglasses?(Required) Yes No Does the examinee have any hearing problems?(Required) Yes No Does the examinee take medication?(Required) Yes No (if yes, please list the medications and reason for taking.)(Required)Rate the examinee's coordination:(Required) Good Awkward / Clumsy Other If "other," please explain:Is the examinee's speech clear to family members?(Required) Yes No Is the examinee's speech clear to strangers?(Required) Yes No Does the examinee relate well to adults (if applicable)?(Required) Yes No Does the examinee relate well to peers?(Required) Yes No Please explain any "no" answers above:(Required) Medical CareExaminee's physician:(Required)Telephone:(Required)Date of last visit:(Required)Has the examinee ever had psychological counseling or therapy?(Required) Yes No Counselor's name:(Required)Telephone:(Required)Type of counseling:(Required)Start date:(Required)End date:(Required)Has the examinee ever had a neurological exam?(Required) Yes No Neurologist's name:(Required)Date of exam:(Required)Reason for exam:(Required)Has the examinee ever had a psychological or psychiatric exam?(Required) Yes No Counselor's name:(Required)Date of exam:(Required)Reason for exam:(Required) Educational HistoryDid the examinee attend preschool?(Required) Yes No Was the examinee ever retained?(Required) Yes No When?(Required)List all the schools the examinee has attended:(Required)(for "special help" - please enter "No" if none was required)Name of School:Grades:Special Help? Type of Help? Add RemoveIs/was the examinee absent from school frequently?(Required) Yes No If yes, why?(Required)Are/were there any concerns about the quality of the examinee's school or teachers?(Required) Yes No Describe:(Required) Family HistoryIs the examinee closer to one parent than the other?(Required) Yes No Which?(Required)Has the examinee ever experienced any parental separations, divorces or death?(Required) Yes No When?(Required)How old was the examinee at the time?(Required)Please describe the circumstances:(Required)If the examinee is a minor and the parents are separated or divorced, who has custody of this minor?(Required)How often does the other parent see this minor?(Required)Who administers the educational rights of this minor?(Required)Brothers/SistersPlease list all brothers and sisters, and any other individuals living with the examinee.AgeSexRelationship to the examineeLiving at home? Add RemoveHow does the examinee get along with others living in the same household?(Required)Family Relations (only for parents answering about a child)(Required)Check the activities in which this child often participates with the family. movies meals conversations visits with relatives church games sports trips television other none What are the examinee's strengths?(Required)What are the examinee's areas for growth?(Required)What is the examinee's level of education?(Required) high school technical or vocational school college law, medical, advanced studies What level of education do you hope this examinee attains?(Required) high school technical or vocational school college law, medical, advanced studies FriendshipsHas the examinee had problems relating to others?(Required) Yes No Please describe:(Required)(only for parents answering about a child)Fights frequently with playmates:(Required) Yes No Prefers playing with younger children:(Required) Yes No Has difficulty making friends:(Required) Yes No Prefers to play alone:(Required) Yes No Please explain:(Required)What role does this child take in peer group games (i.e., leader, aggressor, etc.)?(Required)Recreation/InterestsWhat activities does the examinee enjoy?Sports?(Required)Hobbies?(Required)Other: Family Medical HistoryHave any family members had a history of any of the following?(Required) Cancer Cystic fibrosis Diabetes Heart disease High blood pressure Kidney disease Migraine headaches Multiple sclerosis Physical handicap Stroke Seizures or epilepsy Food allergies Tay-Sachs disease Tourette's syndrome Birth defect Cerebral palsy Alcohol/drug abuse Behavior disorder Emotional disturbance Mental illness Mental retardation Nervousness Learning disabilities Speech/language problem Other None For any boxes checked above, please specify family member's relationship to this examinee.Additional comments: Areas we serve We regularly coach students living in: Atherton Cupertino Emerald Hills Los Altos Menlo Park Mountain View Palo Alto Portola Valley Redwood City San Mateo San Carlos Santa Clara Sunnyvale Stanford Woodside
