Form 407 - Initial Adhd Evaluation Parent Questionnaire
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4Initial ADHD Evaluation Parent Questionnaire
(BLACK INK ONLY PLEASE)
Date: _____________________________
Name: ________________________________________________ DOB: ____________________ MRN: _________________
Teacher: ______________________________________________ Subject: __________________________________________
I. EDUCATION HISTORY
This section to be completed by Parents
School______________________________________________________________________Current Grade________________
Primary Teacher____________________________________________________Total # of Teachers______________________
What grade did school problems start?________________________________________________________________________
Is your child currently receiving additional help?
SSD________________ Other_____________________________________
Has your child had educational testing?
No____ Yes____ If yes, by whom?_________________________________________
Results of testing_________________________________________________________________________________________
Other problems___________________________________________________________________________________________
_______________________________________________________________________________________________________
Areas of concern:
___absenteeism
___peer relations
___memory
___written expression
___classwork completion
___anger control
___risk taking
___motor skills
___attention
___homework
___disobedience
___self esteem
___reading
___distractibility
___health problems
___disruptive behavior
___unhappy @ school
___receptive language
___hyperactivity
___inconsistent performance
___immaturity
___expressive language
___retaining information
___test taking
___motivation
___math
___spelling
Comments on items __________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
II. PAST MEDICAL HISTORY / REVIEW OF SYSTEMS
This section to be completed by Parents
Y N
Y N
1. Does the patient have any ongoing medical problems?
5. Did the mother have any medical problems during
pregnancy, labor, delivery or post delivery period?
2. Do you have concerns about diet, sleep, exercise?
6. Did the patient have difficulty breathing or crying
after delivery, have poor color, poor suck, slow
growth and development?
3. Has the patient had any of the following conditions:
7. Is the patient taking any medication at present?
surgical procedures, significant allergies or allergic
If yes, list medications:
reactions to medications, head injury, seizures, facial
tics or other repeated body movements, meningitis
encephalitis or poisoning of any type?
4. Has the patient had any of the following problems:
8. Has your child been evaluated by an MD or mental
bed wetting, stool soiling, temper outbursts, mood
health professional in the past for school or
changes, anxiety, depression, getting along with
attentional problems?
peers, lying, stealing, fire setting, destructiveness,
cruelty to animals or self injury?
If Yes to any of the above please comment_____________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Form 407 ADHD Parent Questionnaire
rev 3/08
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