Neurodevelopmental Screening questionnaire

Neurodevelopmental Screening(Child)

Neurodevelopment

Neurodevelopmental Screening Questionnaire for Parents/Caregivers

Introduction This questionnaire is designed to help the clinician understand your child’s developmental history, behaviors, learning, and social experiences. It will provide important background information to help assess conditions such as ADHD, Autism, Intellectual Developmental Disorder, or Learning Disabilities. Please answer to the best of your knowledge.

Childs Full Name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age

Parent/Caregiver name

Relation to Child

Primary address (City,State)

Contact info : email & phone

Today's date

Section 1 : Family and Home Environment

1. How many people live in your household?

Name

1a Please list all household members and their relation to your child (e.g., mother, father, sibling):

Name

Relation:

Name

1b Please list all household members and their relation to your child (e.g., mother, father, sibling):

Name

Relation:

Name

1c Please list all household members and their relation to your child (e.g., mother, father, sibling):

Name

Relation:

Name

1d Please list all household members and their relation to your child (e.g., mother, father, sibling):

Name

Relation:

Name

1.2 Does anyone in the family receive now, or is intending to apply for services such as Social Security Disability (SSD), Developmental Disabilities (DD) services, or support from the Department of Human Services (DHS)?

Yes

If yes, please describe:

1.3 How many siblings does your child have?

5. Do any siblings receive school-based services (e.g.,IEP, 504 plan)?

Yes

If yes, please describe:

Section 2 : Pregnancy and Birth History

2.1 Were there any complications during pregnancy or delivery?

Yes

If yes, please describe:

2.2 Was your child born premature (before 37 weeks)?

Yes

2.3 Were there any concerns after birth (e.g., NICU stay, jaundice, feeding issues)?

Yes

If yes, please describe:

Section 3: Developmental Milestones

When did your child achieve the following milestones? (Please estimate if unsure)

Sitting Up independently

in months

Crawling

in months

Walking without help

in months

First words

in months

Combining two words (e.g want juice)

in months

Toilet trained during day

in months

Nighttime dryness

in months

Did your child lose any skills they had previously learned (e.g., talking, social skills)?

Yes

If yes, please describe:

Section 4: Medical, Psychiatric, and Educational Diagnoses

4.1 Has your child ever been diagnosed with any psychiatric, developmental, or learning disorders?

Yes

4.2 If yes, what diagnosis or concern was identified?

ADHD

Autism Spectrum Disorder

Learning Disability

Intellectual Disability

Anxiety

Depression

Other

4.2 Other

4.3 Who made diagnosis? (check all that apply)

Pediatrician

Psychologist

Neuropsychologist

School psychologist

Therapist/Counselor

Psychiatrist

Private Doctor/Agency

4.3 Other

4.4 Are there any ongoing treatments (e.g., therapy, medication, tutoring)?

Yes

If yes, please describe:

Please list any/all medications

Section 5: Attention, Hyperactivity, and Learning

5.1 Does your child have difficulty focusing on tasks like homework or chores?

Never

Sometimes

Frequently

Always

5.2 Is your child often fidgety or restless, having trouble sitting still?

Never

Sometimes

Frequently

Always

5.3 How does your child perform in school compared to peers?

Above average

Average

Frequently

Always

5.4 Does your child receive extra help or services at school (e.g., IEP, 504 Plan, tutoring)?

Yes

If yes, please describe:

Section 6: Social Communication and Behavior

6.1 Does your child make friends easily?

Yes

6.2 Does your child avoid eye contact or seem uninterested in socializing?

Yes

6.3 How does your child handle changes in routine or unexpected events?

Calm and flexible

Upset but adjusts quickly

Extremely upset and resists change

6.4 Does your child engage in repetitive behaviors (e.g., hand flapping, lining up toys)?

Yes

If yes, please describe:

Section 7: Family History

7.1 Does anyone in the immediate or extended family have a diagnosis of ADHD, Autism, Learning Disabilities, Anxiety, Depression, Bipolar Disorder, or other psychiatric or developmental conditions?

Yes

• If yes, please list conditions and relation to the child (e.g., paternal uncle, mother):

7.2 Have any family members been diagnosed with a mental health or developmental condition by a professional (e.g., pediatrician, therapist)?

Yes

• If yes, please explain:

Section 8: Sensory Sensitivities

8.1 Does your child show unusual reactions to any of the following? (Check all that apply)

Loud sounds

Bright lights

Certain textures(clothes,food)

Strong smells

Being touched

None of the above

8.2 How does your child react to these sensitivities?

Ignores them

Mild discomfort

Very upset or avoids them

Section 9: Trauma and Emotional Concerns

9.1 Has your child experienced any significant stressful or traumatic events (e.g., abuse, neglect, witnessing violence, family changes)?

Yes

• If yes, please describe:

9.2 Does your child express frequent worries or fears?

Yes

9.3 Does your child have frequent mood swings or emotional outbursts?

Yes

9.4 Has your child ever expressed feelings of sadness, hopelessness, or thoughts of self-harm?

Yes

• If yes, please describe:

Section 10: Services and Supports

10.1 Has your child received any of the following services? (Check all that apply)

Speech therapy

Occupational therapy

Physical therapy

Counseling or therapy

Developmental Disabilities services

Early intervention services

• Other

10.2 Does your child have a current or previous diagnosis of a developmental, learning, or psychiatric condition?

Yes

If yes, please describe

Final Thoughts

Is there anything else you would like the clinician to know about your child?

Thank you for completing this questionnaire! Your input is valuable and will help guide the evaluation process. Please submit this form before your child's scheduled appointment.