Neurobehavioral Questionnaire

Circle Race Anglo Black Asian Hispanic Nat. Am

Sex Male Female

Circle Blood Type A B AB O Rh+ Rh- Unknown

Completing Questionnaire Relationship to the child Natural Mother Adoptive Mother Grandmother Social Worker Natural Father Adoptive Father Grandfather Caseworker Stepmother Foster Mother Older Sister or Aunt Stepfather Foster Father Older Brother or Uncle

What is the MAIN concern that led you/your child to ProNeuro Health? No problems Depression Anxiety Suicidal thought Suicidal Actions Arguments with adults/parent Refusal to attend school Health Problems Neglect by Parent Fears Adjustment to a divorce Behavior problems in school Physical Abuse Bed Wetting Sexual Abuse Stealing Problems thinking clearly

Severity of this problem Mild Moderate Severe Does not apply

How long has the child had this problem? Past days Past week Past month Past several months Past year Past two years Past several years Does not apply

How is this problem affecting the child Physical health Emotional health Behavior Academic performance Relationship with peers Relationship with family

Has the child been treated for this problem? Yes, with success Yes, but with partial success Yes, but without success No Does not apply

What other problems is the child experiencing? No problems Depression Anxiety Suicidal thought Suicidal Actions Arguments with adults/parent Academic Problems Refusal to attend school Health Problems Neglect by parents Fears Adjustment to a divorce Behavior problems in school Physical Abuse Bed Wetting Sexual Abuse Stealing Problems thinking clearly

Child's school status Has not started school Full-time, regular classes Part-time regular classes Full-time, GT /Pre-AP classes Part-time GT /Pre-AP classes Full-time special education classes Part-time special education classes Classes under 504 plan Home school Tutoring outside of school Ever suspended from school Ever expelled to school

How much education has the child's MALE caretaker completed? Do not know Less than 8th grade 8th grade Some high school High school graduate Career certification Associates Bachelor's Master's Doctorate Law Medical

What is the MALE caretaker's main type of work? Does not apply Do not know Primarily Unemployed Employed within the home Several occupations Labor work Skilled/technical work Sales Business management Military service Small business owner Health professional Social services

Which of the following is true about the child's MALE caretaker's marital history? Does not apply Do not know Never married Not married, in a relationship First marriage Second marriage Married more than twice

How much education has the child's FEMALE caretaker completed? Do not know Less than 8th grade 8th grade some high school high school graduate Career certification Associates college degree Bachelor's degree Master's Degree Doctorate Law Medical

What is the FEMALE caretaker's main type of work? Does not apply Do not know Primarily Unemployed Employed within the home Several occupations Labor work Skilled/technical work Sales Business management Military service Small business owner Health professional Social services

Which of the following is true about the child's FEMALE caretaker's marital history? Does not apply Do not know Never married Not married, in a relationship First marriage Second marriage Married more than twice

Source of household income Does not apply Do not know Father /Male caretaker job Mother/Female caretaker job Both parents/caretakers Welfare Alimony Child support

What is the economic status of the child's household? Does not apply Do not know Poverty Lower Middle Upper

How old was child's natural birth FATHER at the time of child's birth? Do not know 14-19 20-29 20-39 40-49 SO or older

How old was child's natural birth MOTHER at the time of child's birth? Do not know 14-19 20-29 20-39 40-49 SO or older

Describe mother's attitude while pregnant with child? Do not know Accepting Ambivalent Angry Depressed Excited Fearful Happy Moody Worried

What was the child's physical condition immediately after birth? Do not know Normal Normal, no unusual problems Difficult breathing Low birth weight Jaundice Fever Problems with heart Problems with digestion Blood transfusion Intensive care Injured at birth Problems with bones Infection Seizure Incubator

Who was the primary caretaker before the age of 2 years old? Natural Parents Adoptive parents Grandparents Natural Mother Natural Mother & Stepfather Adoptive Mother Grandmother Social Worker Natural Father & Stepmother Adoptive Father Grandfather Stepmother Foster Mother Older Sister or Aunt Stepfather Foster Father Older Brother or Uncle Agency Orphanage

Describe the child's temperament before age 2. Do not know Active Affectionate Alert Angry Cranky Crying Curious Difficult Fearful Happy Hypersensitive Irregular Irritable Playful Regular Sleepy Social Unhappy Withdrawn

How was the child fed before solid food? Do not know Formula bottle Breast milk Formula bottle and Breast milk

From birth to age 2, when did the child develop physical skills such as sitting and crawling? Do not know Before 1 year 1 to 1 ½ years 1 ½ to 2 years After 2 years

When did your child learn to walk? Do not know Before 1 year 1 to 1 ½ years 1 ½ to 2 years After 2 years

When did your child learn to talk? Do not know Before 1 year 1 to 1 ½ years 1 ½ to 2 years

When did toilet training begin? Before 1 year 1year 1 ½ years 2 years 2 ½ years 3 years 3 ½ years 4years After 4 years

Were there any problems toilet training? Do not know No Mild problems Moderate problems Severe problems

Who was the child's primary caretaker from 2-5 years old? Natural Parents Adoptive parents Grandparents Natural Mother Natural Mother & Stepfather Adoptive Mother Grandmother Social Worker Natural Father & Stepmother Adoptive Father Grandfather Stepmother Foster Mother Older Sister or Aunt Stepfather Foster Father Older Brother or Uncle Agency Orphanage

Describe the child's motor development (running, jumping, throwing, use stairs, etc. from ages 2-5. Do not know Slow compared to same age children Average compared to same age children Average compared to same age children

Describe the child's mental development (counting, alphabet, puzzles, understanding concepts) from ages 2-5. Do not know Slow compared to same age children Average compared to same age children Advanced compared to same age children

Describe the child's temperament from ages 2-5. Do not know Active Affectionate Alert Angry Cranky Crying Curious Difficult Fearful Happy Hypersensitive Irregular Irritable Playful Regular Sleepy Social Unhappy Withdrawn

Which of the following care/schools did the child attend? None Infant day care In home daycare Preschool Kindergarten

Did the child have any problems when starting kindergarten? Does not apply Do not know Fear Complained of being ill to avoid Punished to enforce school attendance Coerced/rewarded to attend school

Which of the following describes the child's pre-K or kindergarten experience? Does not apply Do not know Neutral about school Disliked school Enjoyed school

Which describe the child's behavior in kindergarten? Does not apply None Active Aggressive Distracted Disobedient Fearful Withdrawn

At what age did the child start 1st grade? Does not apply Age 5 Age 6 Age 7 Age 8 or older

Describe the child's academic performance in 1st grade? Does not apply Do not know Poor grades Average grades Good grades Excellent grades

Describe the child's experienced in 1st grade. Does not apply Do not know Frequently absent Received school counseling Evaluated by school psychologist Evaluated by school diagnostician Suspended Expelled Entered into 504 Part-time specialized help Part-time special education Full-time special education Accelerated academics

Describe the child's academic performance since 1st grade. Does not apply Do not know Poor grades Average grades Good grades Excellent grades

Describe your child's experiences since 1st grade. Does not apply Do not know Frequently absent Received school counseling Evaluated by school psychologist Evaluated by school diagnostician Suspended Expelled Entered into 504 Part-time specialized help Part-time special education Full-time special education Accelerated academics

Describe the child's subject STRENGTHS in school. Does not apply Do not know None Art English History Math Music Reading Science Social studies Spelling

Describe the child's subject WEAKNESSES in school. Does not apply Do not know None Art English History Math Music Reading Science Social studies Spelling

Describe the child's current SKILL STRENGTHS in school. Does not apply Do not know Accurate math computation Appropriate behavior Assignments completed on time Checks work before turn in Concentration Handwriting Intelligence Memorizing Paying attention in class Organization Paper assignments Pleasing the teacher Reading comprehension Reading speed Reports Test preparation Test taking Understanding concepts Vocabulary Vocal expression Working hard Written expression

Describe the child's current SKILL WEAKNESSES in school. Does not apply Do not know Accurate math computation Appropriate behavior Assignments completed on time Checks work before turn in Concentration Handwriting Intelligence Memorizing Paying attention in class Organization Paper assignments Pleasing the teacher Reading comprehension Reading speed Reports Test preparation Test taking Understanding concepts Vocabulary Vocal expression Working hard Written expression

Does the child have any classroom behavior concerns? Does not apply None Can't wait for his/her turn Talks out of turn Difficulty staying seated Difficulty following directions Needs to sit away from distractions Required to sit in isolated area Often reprimanded Sent to principal's office Required to sit near teacher

Does the child currently have problems with attention and concentration in the classroom? Does not apply Daydreaming Difficulty being quiet Difficulty sitting still Disorganized Forgets teacher instructions Impulsivity Incomplete assignments Messy

How is the child described by teachers? Does not apply Do not know Answers questions too quickly Distractible Fidgety Interrupts Problems maintaining attention Frequently loses objects Problems remaining seated Doesn't wait turns Fails to finish assignments Switches from one unfinished task to another Talks excessively Doesn't listen Fails to consider safety Frequently pays attention to questions Not easily distracted Able to remain seated Maintains attention for instruction/ assignments Waits turns Talks appropriately Listens to teacher and peers

Which of the following are true? Do not know None Child has regular hearing tests Child has regular vision tests Child has regular medical checkups Child wears glasses Child wears hearing aid Child wears orthopedic brace Child wears orthopedic/corrective shoes Child uses crutches for walking

What problems does the child have with sleep? None Trouble falling asleep Not getting enough sleep Restlessness in bed Sleeping enough, but still tired Refusing to go to bed at night Wakes up often at night Sleeping too much Waking up too early I the morning Falling asleep at school Refusing to get up in the morning Sleeping enough, but still tired Refusing to go to bed at night Sleepwalking Nightmares or night tremors

What problems does the child have with eating? None Finicky about food textures Finicky about food flavors Refuses to eat a balanced diet Eats too many snacks Poor appetite Overeats

Does the child have trouble soiling or wetting? No Occasionally wets the bed Frequently wets the bed Frequently wets pants Occasionally soils bed Frequently soils bed Frequently soils pants

What types of discipline measures are used for the child? Does not apply Do not know None Yelling Grounding Lectures Loss of allowance Physical punishmen Financial rewards Gift rewards Food rewards Negotiations

How strict are the parents/caretakers? Does not apply Do not know Very strict Strict Average Permissive Very permissive

Has the child ever been abused by a current or previous household member? Does not apply Do not know No Yes, emotionally Yes, verbally Yes, sexually Yes, physically Yes, neglected

Which describes the child now? Do not know Has many close friends Has a few close friends Has several close friends Has no close friends

How does the child perceive his or her level of acceptance with others? Do not know Poor Mixed Good Excellent

Which problems, if any, does the child have with peers? Do not know None Being teased Being physically attacked Being rejected Peer who have delinquent behavior Being jealous Peers who have poor grades Problems sharing Always wants things his or her way

How does the child participate in games with others? Do not know Does not participate Passively participates Actively participates Cheats occasionally Cheats regularly No interest in winning Strong drive to win

Does the child have imaginary playmates? Do not know Never has Had in the past, but not now Has currently

Psychological Evaluation Normal Abnormal

Wechsler Preschool & Primary Scale of Intelligence Normal Abnormal

Wechsler Preschool & Primary Scale of Intelligence Normal Abnormal

Speech and Language Evaluations Normal Abnormal

Genetic Evaluations Normal Abnormal

Neurological Evaluations Normal Abnormal

Gastroenterology Evaluations Normal Abnormal

Celiac/Gluten Testing Normal Abnormal

Allergy testing Normal Abnormal

Auditory Testing Normal Abnormal

Vision Evaluation Normal Abnormal

Osteopathic Normal Abnormal

Acupuncture Normal Abnormal

Physical Therapy Normal

Occupational Therapy Normal Abnormal

Sign Language Normal Abnormal

Homeopathic Normal Abnormal

Naturopathic Normal Abnormal

Craniosacral Normal Abnormal

Chiropractic Normal Abnormal

Intelligence Tests Normal Abnormal

Place a check mark if any of the following occurred during pregnancy and describe if applicable. Difficulty getting pregnant ( more than 6 months) Infertility drugs used In Vitro Fertilization Forceps used in delivery Drink Alcohol Drink Coffee Smoke Tobacco Used Progesterone Used Prenatal vitamins Used antibiotics Used other drugs Excessive vomiting, nausea (more than 3 weeks) A viral infection Amalgam filling put in teeth Experienced bleeding & which months Problems in delivery Group B strep infection C-section & why Induced labor Oxygen during labor An x-ray Rhogam Gestational diabetes High-blood pressure (pre-eclampsia) High blood pressure/toxemia Chemical exposure Moved to newly built home House painted indoors House painted outdoors House exterminated for insects

Check if any of the following apply: Very active before birth Hospital Birthing Center Needed newborn special care Appeared healthy Easily consoled in first month Antibiotics during first month Experienced no complications first month of life