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Luzio & Associates Behavioral Services, Inc.
Parent's Questionnaire
For Child and Adolescent Assessments
DEVELOPMENTAL HISTORY
Child's Name
Were there any complications with mother or child during pregnancy, labor, or delivery?
(e.g. toxemia, eclampsia, Rh Factor, forceps delivery, C-section, breech birth, normal birth weight, low Apgar score, jaundice, etc.)
Yes
No
If yes, please describe:
List all prescription medications taken during the pregnancy:
How far in pregnancy when found out pregnant?
Was pregnancy planned?
Any problems with post partum depression?
Check any of the following which were used during pregnancy:
Beer
Wine
Hard Liquor
Caffeine (coffee, coke, etc.)
Tobacco products
Nonprescription drugs (marijuana, cocaine, crank, etc.)
If yes, how much and how often?
Any issues during pregnancy with stress, domestic violence, etc.?
Describe child as an infant and toddler (sleep, eating, colic, etc.)
When did your child acheive the following milestones?
Smiling (range: 2-6 months)
Early
On-Time
Late
Sitting up (range: 6-8 months)
Early
On-Time
Late
Crawling (range: 7-10 months)
Early
On-Time
Late
Fear of strangers (range: 7-10 months)
Early
On-Time
Late
Walking independently (range: 10-16 months)
Early
On-Time
Late
Using meaningful words (range: 12-24 months)
Early
On-Time
Late
Using short sentences (range: 24-36 months)
Early
On-Time
Late
Was this child clumsy or awkward (accident-prone)?
Yes
No
Were you ever told that you child is "mentally handicapped" or "retarded" or "developmentally delayed"?
Yes
No
List any problems in the child's growth or development during the first three years, including problems with eating, sleep, toilet-training, motor development, language development, social development, behavior, etc.
Were there any problems with toilet training?
Yes
No
If yes, please explain:
Was it frequently difficult putting the child to bed?
Yes
No
If yes, did the child wake up screaming but couldn't remember doing that the next day?
Yes
No
N/A
If yes, did the child have nightmares?
Yes
No
N/A
Describe the nightmares:
When is child's normal bedtime?
When does child get up?
Do you have a bedtime routine?
Did the child come to the parent's bedroom?
Yes
No
Did the child sleep in the parent's bed?
Yes
No
Did the parent(s) stay in the child's room?
Yes
No
On a regular basis, does the child sleep alone?
Yes
No
If not, with whom?
Was this child easy or difficult to care for and live with?
Easy
Difficult
During the child's first 5 years of life, was mother/primary caregiver frequently away from the child for a period of 5 days or more?
Yes
No
Frequently away from the child overnight?
Yes
No
If yes, what provisions were made for the care of the child?
Has child had any of these problems?
Frequently running off, difficult to keep track of
Couldn't stay at the table to eat, or stay at a game?
Being unusually excitable, so you dreaded taking him/her everywhere
Being unusually impulsive, so he/she seemed unaware of danger
Frequent temper outbursts beyond age 4
Destructiveness of toys or property
Being unable to follow directions or rules
Setting fires or playing persistently with lighters/matches
Being overly demanding and demands had to be made at once
Being unusually withdrawn
Being unusually aggressive, biting, kicking with little/no provocation
Nervous habits like nail biting or hair twisting
Unusual body movement
Rocking
Twirling
Head banging
Repetitive blinking
Tics
Twitches
Sounds
Throat-clearing
Grunts
Profane words
Bizarre or unusual speech or inability to sustain conversation
Preoccupation/attachment with objectsparts
Insistence on routines and distress over trivial changes
Poor eye contact/problems understanding body language
Problems making peer relationships appropriate to developmental level
Other problems:
Does child attend daycare?
Yes
No
If yes, any problems:
Nursery/Preschool/Head Start
Yes
No
If yes, any problems:
Kindergarten?
Yes
No
If yes, any problems:
EDUCATIONAL HISTORY
What grade is the child in?
List current and previous schools attended by the child.
Does your child seem to like school?
How well is the child doing in school academically?
Has the child ever skipped a grade or been held back a grade?
What subjects does the child seem to be having difficulty with?
What behavioral difficulties is the child having in school?
Is the child in special education? (If so, what for and how long?)
Is the child receiving any tutoring or other special help with school?
Check any of the following that describe the child:
Does not have homework
Does not do homework
Takes a long time to do homework
Does not finish homework
Does sloppy work
Loses papers
Hurries through homework
Makes many careless errors on homework
Forgets what the assignments are
Does not bring home books and papers to do
Does not turn in assignments
What other information would be helpful to use in understanding your child and your child's problems?
What are your goals for therapy or treatment for your child?
List child's strengths:
Signature
Relationship to Client
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