Neuro History Questionnaire

Details of person completing this form

Student Information

Reason for Referral

What are the student’s strengths and weaknesses?

What are your primary concerns for the student?

Language

 
If the student is exposed to MORE THAN ONE LANGUAGE, respond to the following:
 

Student’s Family Members

Others living in the home:
 

Others living in the home:
 

Student’s Family History

Is there a family history of any the following?
1. Check all that apply.
2. Specify the biological family member with the history, and then describe the specific problem.
 

Pregnancy and Birth

Check the conditions listed below that best describe the mother’s and student’s health.
 

Developmental Milestones

Indicate the approximate month the student obtained each skill, if known.

 

Sat alone

Crawled

Walked alone

Fed self

Dressed self

Started babbling

Spoke first word

Spoke short phrases

Spoke in sentences

Followed simple directions

Fully bladder-trained

Fully bowel-trained

Stayed dry all night

Early Behavior

During the student’s first few years of life, were any of the following behaviors present to a significant degree? Check all that apply.

 

Student’s Early Temperament

Toddler through five years of age

Prior to age six, did the student have more difficulty than other students the same age with any of the following? Check all that apply.

Student Health

Student Hospitalizations
 

Has the student had any of the following?

1. Check all that apply.
2. Describe, and provide details, dates, and/or age of onset.

 

Current Behavior

Home Behavior

How often are the following settings a problem for the student?

 

How does the student get along with family members and other children and adults?

 

How much time does the student typically spend on electronic media?

 

Social Behavior

Student’s Educational History

List schools the student has attended, and then describe the student’s academic and/or behavioral performance.

 

Preschool/Daycare:

Elementary School:

Middle School:

High School:

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