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CHILDREN'S

NEUROPSYCHOLOGICAL
Fernando Melendez, Ph.D.

QUESTIONNAIRE

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Name Parent's Address Age Pediat~cian's Sex Name and Address Date Phone Names

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1. Birth history: Describe anything unusual about pregnancy or delivery

YES NO

2. Walking, talking, toilet training were normal? Ages? 3. Was feeding development normal? 4. Did your child go to kindergarten? 5. Has your child's school history been normal?

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6. Does your child get along well with other kids?

7. Does your child have "spells?"

8. Does your child complain of headaches? 9. Is your child clumsy? 10. Does your child bump into things or fall often? 11. Has your child ever had a head injury? 12. When was your child last seen by a physician? 13. Has the way your child talks changed, lately? 14. Has your child's school work changed?

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COPYRIGHT

1978 PSYCHOLOGICAL

ASSESSMENT

..---YES NO

15. What subjects 16. Subjects

is your child good at in school?

that your child is very poor at

17. Does your child have dizzy spells sometimes? 18. Does your child often vomit? 19. Sometimes, does your child fall deeply asleep even though it is not his bed
time?

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D

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20. Does your child have nightmares? 21. Does your child's
memory seem to have changed, recently?

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22. Does your child's walk seem to have changed? 23. Sometimes,
does your child start crying for no apparent reason?

24. Does your child have temper tantrums? 25. Does your child wet the bed from time to time? 26. Does your child sometimes stare blankly into space? 27. Sometimes does your child start to say something, blank out
and forget what he/she was saying?

28. Do you sometimes

twitching

notice a muscle or group of muscles in your child?

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29. Does your child sleep-walk? 30. Does your child sometimes get so excited that it is impossible to control him/her? 31. Describe any particular food that your child craves at times 32. Is your child on any kind of medication? 33. Does your child lie or steal? 34. Has your child been known to set fires or play with matches?
35. Is there any adult that your child

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is terrified

of?

36. Any child?

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37. Has your child been known to engage in sexual play? 38. Does your child sleep alone? 39. Known allergies 40. Does your child sometimes complain of stomach cramps or pains? 41. Describe the thing your child has done for which he/she received the greatest punishment 42. List all childhood diseases and ages:

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ADDITIONAL INFORMATION

ADDITIONAL INFORMATION