Patient History Form Page 7
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7Please list previous psychological/academic evaluations (please provide copies): _______________________
__________________________________________________________________________________________
To the best of your knowledge, at what grade level is your child functioning?
Reading:
Below grade level
On grade level
Above grade level
Spelling:
Below grade level
On grade level
Above grade level
Writing:
Below grade level
On grade level
Above grade level
Arithmetic:
Below grade level
On grade level
Above grade level
Has your child ever repeated a grade? _________ If so, when? _______________________________________
As best you can recall, please use the following space to provide a general description of your child’s school
progress, including schools attended. Use the back of this form if extra space is needed. Please attach samples
of report cards or yearly testing.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Has your child ever received any of the following?
Tutoring
Speech/Language Therapy
Counseling
One-to-one Aid
PT
Remedial Services
Special Education
Gifted Testing
OT
Individual Edu. plan (IEP)
504 Accommodation plan
Other (Describe) ____________________________________________
Are there any other risk issues, self-harm, or safety concerns?: _______________________________________
__________________________________________________________________________________________
Signed: ____________________________________________________
Relationship to Child:_________________________________________
Family Psychology
Associates
Date:______________________________________________________
727.725.8820
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