INTAKE PACKET CHECKLIST
Children over 5 years
Please complete all relevant questions on the Intake Form.
Please complete and sign the Insurance Information/Authorization of the Intake
Questionnaire.
If you have copies of any recent evaluations (psychological, developmental testing,
speech/language, hearing, vision), please include them when you send us your Intake Form.
Please include copies of your child’s IEP and/or the results of any school
testing/evaluations.
If you are the child’s guardian and not the birth or adoptive parent, please include copies of the
Guardianship papers (court order or Power of Attorney) with your Intake Form.
If your child is in a school, preschool, or daycare setting, please have his or her teacher(s) fill
out the Educational Questionnaire and send it back to us.
If you need help in filling out the Intake Form, please call (205) 638-2294 and we will help you
with your questions.
Please return all Intake materials by mail or fax to:
Developmental Medicine Clinic
1600 7th Avenue South
Dearth Tower Suite 5602
Birmingham, AL 35233
Phone: (205) 638-2294
Fax: (205) 212-2994
We look forward to working with you and your family. If you do not hear from us 2 weeks after
sending the packet to us, please call the number above to make sure we have received your
packet.
Thank you,
The Developmental Medicine Clinic
Children’s of Alabama
Page 1
Developmental Medicine Clinic
Children over 5 years
(rev. 2016-11-21)
About Your Child:
Name:___________________________________________________________________________
Last
First
Date of Birth:___________________
Gender:
MI
Male
Female
Nickname
Race:______________
Address:_________________________________________________________________________
Street
City
Apt or Unit #
State
Zip Code
County
Reason for Coming to Clinic:
What three specific questions about your child’s development or behavior would you like to ask us?
1)____________________________________________________________________________
2)____________________________________________________________________________
3)____________________________________________________________________________
Who referred you to us?
___________________________
_____________________________
_________________
Name
Organization
Phone Number
_______________________________________________________________________________
Primary Medical Provider (if different from above)
Location
Phone Number
Important Information:
What languages do you speak at home?_______________________________________________
Do you or your child need an interpreter for your visit? ☐Yes ☐No
Do you or your child need any special assistance for your visit? ☐Yes ☐No If yes, describe:
________________________________________________________________________________
________________________________________________________________________________
Page 2
Your Contact Information:
Parent/Caregiver 1:
Name:_________________________________________________
Last
First
Relationship to child:______________________________________ Legal Guardian?
Yes
No
Address:_________________________________________________________________________
Street
City
Apt or Unit #
State
Main Phone:________________
Zip Code
County
Alternate Phone:_______________
E-mail Address:_________________________________
Parent/Caregiver 2:
Name:_________________________________________________
Last
First
Relationship to child:______________________________________ Legal Guardian?
Yes
No
Address:_________________________________________________________________________
Street
City
Apt or Unit #
State
Main Phone:________________
Zip Code
County
Alternate Phone:_______________
E-mail Address:_________________________________
Legal Guardian (if different from above):
Name:_________________________________________________
Last
First
Relationship to child:______________________________________
Address:_________________________________________________________________________
Street
City
Apt or Unit #
State
Main Phone:________________
Zip Code
County
Alternate Phone:_______________
E-mail Address:_________________________________
Page 3
Pregnancy & Birth:
Check if birth history is not known.
Was your child born on time?
Yes
No
Number of weeks:______
At the time of birth, how old was: Mother:_______ Father:________
How many times has mother been pregnant before this child?_____
How many:
Miscarriages?___
Any problems during pregnancy?
Abortions?____
Yes
Stillbirths?____
No
If yes, please explain:_______________________________________________________________
________________________________________________________________________________
During pregnancy, did mother take:
Prescription medications?____________________________________________________________
Vitamins or supplements?____________________________________________________________
Drugs?
Yes
No
If yes, list:________________________________________________
Smoke?
Yes
No
If yes, how many packs a day?____________
Drink alcohol?
Yes
No If yes, how much?__________________________________________
Where was baby born?______________________________________________________________
Name of Place
Was the baby born:
Naturally (vaginally)
City
State
C-section
If C-section, why?__________________________________________________________________
Any problems during delivery?
Yes
No
Apgars (if known)? ___1 min ___5 min
If yes, please explain:_______________________________________________________________
________________________________________________________________________________
How long did baby stay in the hospital?___________ Which hospital?________________________
Any medical problems while in the hospital?
Breathing problems
Heart problems
Feeding problems
Infections
Brain problems
Stomach problems
Eye problems
Skin problems
If any problems, please explain:_______________________________________________________
________________________________________________________________________________
Birth weight:___________
Was baby:
Breastfed
Birth length:___________ Head circumference:____________
Bottle fed
If breastfed, for how long?_____________
Page 4
Your Child’s Development:
When did your child first:
Not Yet
Early
On Time
Late
If known, at what age?
Roll over?
Sit without support?
Crawl?
Walk?
Say first words?
Put two words together?
Say whole sentences?
Become dry during day?
Become dry at night?
Become bowel trained?
How old was your child when you first became worried about his/her development? ___________
What worried you at that time?_____________________________________________________
Did your child ever stop doing any skills that he/she had learned?
Yes
No
If yes, please explain:_______________________________________________________________
How does your child communicate (check all that apply)?
Crying/Whining
Single words
Electronic devices/tablets
Playful sounds
Short phrases
Picture communication boards
Pointing
Sentences
Grabbing/Using your hand
Are you worried about your child’s social or play skills?
Yes
Sign language
Facial expressions
No
If yes, please explain:_______________________________________________________________
________________________________________________________________________________
Are you worried about your child’s:
Toileting? Yes
No
If yes, explain:____________________________________________
Feeding? Yes
No
If yes, explain:____________________________________________
Sleep?
Yes
No
If yes, explain:____________________________________________
Please tell us what your child is good at doing. What are his/her strengths?_____________________
________________________________________________________________________________
Please tell us what your child likes to do for fun or play with:_________________________________
________________________________________________________________________________
Page 5
Your Child’s Behavior:
Circle the number that best describes your child’s
behavior OVER THE PAST 6 MONTHS
1. Fails to give close attention to detail or makes careless
mistakes (e.g. homework)
2. Has difficulty attending to what needs to be done
3. Does not seem to listen when spoken to directly
4. Does not follow through when given directions
5. Has difficulties organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks
7. Loses things necessary for tasks or activities (school
assignments, books, pencils, etc.)
8. Is easily distracted by noises or other things
9. Is forgetful in daily activities
Office Use Only (I)
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when he/she is supposed to stay in seat
12. Runs about or climbs too much when he/she is
supposed to stay seated
13. Has difficulty playing or starting quiet games
14. Is “on the go” or acts as if “driven by a motor”
15. Talks too much
16. Blurts out answers before questions have been
completed
17. Has difficulty waiting his/her turn
18. Interrupts or bothers others when they are talking or
playing games
Office Use Only (HI)
19. Argues with adults
20. Loses temper
21. Actively disobeys or refuses to follow adult’s request or
rules
22. Bothers people on purpose
23. Blames others for his or her mistakes or misbehaviors
24. Is touchy or easily annoyed by others
25. Is angry or bitter
26. Is hateful and wants to get even
Office Use Only (ODD):
Page 6
Never or
Rarely
0
Occasionally Often
1
2
Very
Often
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
0
1
1
2
2
3
3
(1-9)___/9
> 6/9
SUBTOTAL:______
0
0
0
1
1
1
2
2
2
3
3
3
0
0
0
0
1
1
1
1
2
2
2
2
3
3
3
3
0
0
1
1
2
2
3
3
(10-18)___/9
> 6/9
SUBTOTAL:______
0
0
0
1
1
1
2
2
2
3
3
3
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
(19-26)/8
> 3/8
Circle the number that best describes your child’s
behavior OVER THE PAST 6 MONTHS
27. Bullies, threatens, or scares others
28. Starts physical fights
29. Lies to get out of trouble or to avoid jobs (i.e. “cons”
others)
30. Skips school without permission
31. Is physically unkind to people
32. Has stolen things that have value
33. Destroys others’ property on purpose
34. Is physically mean to animals
35. Has set fires on purpose to cause damage
36. Has broken into someone else’s home, business, or car
37. Has stayed out all night without permission or run away
from home overnight
38. Has used a weapon that can cause serious physical
harm (e.g. bat, broken bottle, brick)
Office Use Only (CD):
39. Is fearful, anxious, or worried
40. Is afraid to try new things for fear of making mistakes
41. Feels useless or inferior
42. Blames self for problems, feels at fault
43. Feels lonely, unwanted, or unloved; complains that “no
one loves me”
44. Is sad or unhappy
45. Feels different and easily embarrassed
46. Is overly concerned about health/body
Office Use Only (Anx/Dep):
47. Has problems getting along with parent(s)
48. Has problems getting along with others his/her own age
49. Has problems getting along with his/her own siblings
50. Has problems in group activities such as games or
team play
Office Use Only (Soc):
51. Decreased interest in pleasure in all, or almost all,
activities of the day
52. Has said things like “I wish I were dead” or has tried to
hurt self
53. Recurrent excessive distress when separation from
home or caretakers
54. Has distinct periods of unusually irritable or unusually
cheerful mood (different from normal)
55. Has prolonged temper tantrums (greater than 20-30
minutes)
56. Hears voices others do not hear
57. Has compulsions (e.g. child seems driven to wash
hands, count, erase until holes appear)
Page 7
Never or
Rarely
0
0
0
Occasionally Often
1
1
1
2
2
2
Very
Often
3
3
3
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
0
1
2
3
(27-38) ___/12
>3/12
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
(39-46)___/8
0
0
0
0
> 3/8
1
1
1
1
2
2
2
2
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
0
1
1
2
2
3
3
(47-50)___/4
3
3
3
3
> 1/4
Circle the number that best describes your child’s
behavior OVER THE PAST 6 MONTHS
58. Has obsessions (e.g. persistent or repetitive distressing
thoughts: germs, doors left unlocked)
59. Has recurrent recollections or dreams of a traumatic
event
60. Seems to avoid or have phobias of specific people,
animals, things, or situations
61. Seems unaware of others’ existence, is uninterested in
interacting with others
62. Has odd, eccentric, or unusual preoccupations (e.g.
clothing items, toys, neatness)
63. Appears uninterested in activities children his or her
age usually like or participate in
64. Has experimented with or abused drugs or alcohol
Office Use Only (MH):
Never or
Rarely
0
Occasionally Often
1
2
Very
Often
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
(51-64)___/14
3
> 0
Other concerns:
What do you do when your child gets in trouble?
Time Out
Spanking
Yell at him/her
Take away something fun
Other:________________________________________________________________________
Does what you do usually help?
Yes
No
Page 8
Your Child’s School:
School Name:___________________________________________ Grade:___________________
Main Phone:________________
Fax:_______________
Does your child have an Individualized Education Plan (IEP)?
Does your child have a 504 Plan?
Yes
No
Yes
No
Please list all services (physical therapy, occupational therapy, speech, ABA, etc.) that your child
receives in school:__________________________________________________________________
Does your child receive services outside of school?
Yes
No
If yes, please list all services and where:________________________________________________
________________________________________________________________________________
Please circle the number that best describes your child’s current performance at school, or check
“not applicable.”
Not
Excellent
Above
Average Somewhat Problematic
applicable
Average
of a
problem
1. Overall school performance
1
2
3
4
5
2. Completing classroom
1
2
3
4
5
assignments
3. Completing homework
1
2
3
4
5
4. Getting homework to and
1
2
3
4
5
from school
5. Organizational skills
1
2
3
4
5
6. Reading
1
2
3
4
5
7. Spelling
1
2
3
4
5
8. Mathematics
1
2
3
4
5
9. Science
1
2
3
4
5
10. Written Expression
1
2
3
4
5
11. Handwriting
1
2
3
4
5
How does your child get along with other children at school?_________________________________
________________________________________________________________________________
How is your child’s behavior at school?_________________________________________________
________________________________________________________________________________
Any other information that you would like us to know about how your child does at school?_________
________________________________________________________________________________
________________________________________________________________________________
Has your child had any previous evaluations for concerns about development, behavior, or school?
_______________________________________________________________________________
_______________________________________________________________________________
________________________________________________________________________________
Please include a copy of your child’s most recent IEP and any reports from
previous evaluations along with this paperwork.
Page 9
Your Child’s Medical History:
Please tell us whether your child has problems now or in the past with:
If yes, please explain:
Eyes/Vision
☐Yes ☐No ☐Don’t Know
Ear, Nose, Throat
☐Yes ☐No ☐Don’t Know
Hearing
☐Yes ☐No ☐Don’t Know
Stomach/Intestines/Bowels
☐Yes ☐No ☐Don’t Know
Heart problems
☐Yes ☐No ☐Don’t Know
Heart rhythm problems
☐Yes ☐No ☐Don’t Know
Lung/Breathing problems
☐Yes ☐No ☐Don’t Know
Blood problems (anemia, leukemia, etc.) ☐Yes ☐No ☐Don’t Know
Brain/Neurologic problems
☐Yes ☐No ☐Don’t Know
Muscle or movement problems
☐Yes ☐No ☐Don’t Know
Skin problems
☐Yes ☐No ☐Don’t Know
Thyroid problems
☐Yes ☐No ☐Don’t Know
Diabetes
☐Yes ☐No ☐Don’t Know
Other endocrine/hormone problems
☐Yes ☐No ☐Don’t Know
Joint or bone problems
☐Yes ☐No ☐Don’t Know
Kidney problems
☐Yes ☐No ☐Don’t Know
Genetic or hereditary problems
☐Yes ☐No ☐Don’t Know
Accidents or injuries
☐Yes ☐No ☐Don’t Know
Mental health/emotional problems
☐Yes ☐No ☐Don’t Know
Learning problems (dyslexia, etc.)
☐Yes ☐No ☐Don’t Know
Intellectual Disability/Mental Retardation ☐Yes ☐No ☐Don’t Know
Autism spectrum
☐Yes ☐No ☐Don’t Know
Attention deficit (ADHD, ADD)
☐Yes ☐No ☐Don’t Know
List surgeries or operations your child has had below: ☐None
Surgery type
Which hospital?
Date of surgery
Please list times your child had to stay in the hospital overnight: ☐None
Hospital name
Why?
Dates of hospital stay
Are your child’s shots up to date? ☐Yes ☐No (explain):__________________________________
Has your child ever had:
MRI or CT scan? ☐No ☐Yes (explain):_______________________________________________
Genetic testing? ☐No ☐Yes (explain):_______________________________________________
Hearing test by a hearing specialist? ☐No ☐Yes (explain):________________________________
Other procedures or medical tests? ☐No ☐Yes (explain):_________________________________
________________________________________________________________________________
Page 10
Your Child’s Medications and Allergies:
Please list all medications your child takes now:
Name
Dose
How often?
Date started
Who prescribes?
Does it help?
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
Who prescribed?
Did it help?
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
If you need more room, please write on a new sheet of paper.
Please list all medications your child has taken in the past:
Name
Dose
How often?
Dates taken
If you need more room, please write on a new sheet of paper.
Please write any vitamins, herbals, or supplements your child takes below:
________________________________________________________________________________
________________________________________________________________________________
Please list all allergies, including your child’s reaction (hives, trouble breathing, etc.), below:
Food:____________________________________________________________________________
Medicines/Drugs:___________________________________________________________________
Environmental/Seasonal:____________________________________________________________
Does your child eat a special diet? ☐No ☐Yes (explain):_________________________________
________________________________________________________________________________
Please tell us other information about your child’s medical history that you think we should know:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Page 11
About the Family:
What is your child’s living/custody arrangement (check all that apply)?
☐Birth Mother ☐Birth Father
☐Guardianship
☐Foster Care
☐Adoptive Family
☐Other (explain):_________________________________________________________________
If child is in foster care or in an adoptive family, how old was the child when he/she came into your
home?_________________
Please list everyone currently living in the child’s home, including you (use separate sheet if needed):
Name (first and last) Birthdate How related to child? Highest education
Job/Work
Please list any birth parents and/or siblings not living in the child’s current home:
Name (first and last) Birthdate How related Highest
Job/Work
Where does he/she live?
(or age) to child?
education
How often does your child get to see the other family members listed above who live elsewhere?
________________________________________________________________________________
Is there anything about your family’s religion, traditions, culture, or practices of your family that you
would like us to know?
________________________________________________________________________________
________________________________________________________________________________
Has the Department of Human Resources (DHR) ever been involved with your family? ☐Yes ☐No
If Yes, please explain:_______________________________________________________________
________________________________________________________________________________
Page 12
Family Medical History:
Please tell us whether any of the child’s biological family members has any of the following.
Biological family members (related to the child by blood) include mother, father, grandparents,
brothers, sisters, aunts, uncles, and first cousins.
Condition
Mother’s Side
Father’s Side
Who? And what problem?
Who? And what problem?
Autism/Asperger’s/PDD
Developmental Delay
Learning Problems
Intellectual Disability
(formerly mental
retardation)
ADHD or ADD
Speech or language
problems
Tics or other
movements
Seizures/Brain problems
Severe emotional problems
(depression, bipolar, etc.)
Anxiety
Schizophrenia or
psychosis
Alcohol/drug problems
Stillbirths
Birth defects
Heart problems
Heart rhythm problems
Sudden, unexplained death
Diabetes
Thyroid problems
Hearing loss/problems
Eye problems
Genetic/Hereditary
problems
Other:
Thank You!
___________________
Signature
___________________
Printed Name
___________________
Relationship to Child
Page 13
____________________
Date Completed
Please return to:
Developmental Medicine Clinic
1600 7th Avenue South
Dearth Tower Suite 5602
Birmingham, AL 35233
Fax: (205)212-2994
Children’s Health System-Authorization for Release of Information
Patient Name (First, Last, MI):_________________________________________________________________
Address:__________________________________________________________________________________
Phone Number: (_____)____________________________Date of Birth:_______________________________
This Authorization applies to the following Information:
All Information. I understand that the information may contain psychiatric/psychological, alcohol/drug abuse, and/or HIV
information and I expressly consent to the release of the information.
Only the following records or types of Information: __________________________________________
_________________________________________________________________________________________
Treatment Dates: from (month/day/year) ______/______/______ to (month/day/year) ______/______/______
The Information may be released as follows:
by to (Please check all that apply)
X X
1600
Children’s Health System (Please provide address & phone number):Developmental Medicine Clinic,
7th
Avenue South, Dearth Tower, Suite 5602, Birmingham, AL 35233; (205)638-2294; FAX (205)212-2994
External Individual/Agency/Organization (Please provide address & phone number):________________
_________________________________________________________________________________________
Purpose of the release:
X Continuity of Treatment
Other (Please specify):__________________________________________
I understand the Information released will be limited to information necessary to fulfill the need or purpose
for the disclosure. If I have authorized the disclosure of Information to a recipient who is not subject to the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), then the recipient may re-disclose it
and it may no longer be protected under HIPAA, a federal privacy law. This Authorization is valid for ninety
(90) days from the date of signature, unless otherwise noted. This Authorization only applies to treatment
occurring before the date of signature. I may decline to sign this Authorization. I understand I may revoke
this authorization in writing at any time by completing a form available from Medical Information Services. If
I revoke this authorization, the revocation will not apply to information that has already been released in
response to this authorization. I understand the patient’s health care and the payment for the patient’s
health care will not be affected if I do not sign this form. I understand I may see and copy the Information
described on this form if I ask for it, and I may receive a copy of this form after I sign it. Before requesting
medical record copies, please about the copy fee by law that may apply. I represent that I have the authority
to and voluntarily grant permission for the Information to be released as described above.
__________________________________
____________________________________
Patient/Parent/Legal Guardian Printed Name
Patient/Legal Guardian Signature
_________________________________________
____________________________________________
Patient Signature (if 14 or older)
Witness Signature
Date
Date
Date
DEVELOPMENTAL MEDICINE CLINIC
EDUCATIONAL QUESTIONNAIRE (Over 5)
Child and Parent Information:
Child’s Name: ___________________________________________________ Birth Date: _________________
Last
First
Middle
Gender:
Male
Female
Child’s Classroom/Age Level:___________________________________
Parent’s Name: ____________________________________Relationship to child:_______________________
Please have teacher(s) or child care personnel fill out and return. You may make
copies if needed for more than one teacher.
Form Completed by ______________________________________ Date Completed:______________
Position/Title_____________________________________________
How long have you known the child?__________________
Child Care/School:_______________________________________________________________________
Address: ________________________________________________________________________________
Street
City
State
Zip
County
Primary Phone:_____________________________Fax Number: _____________________________
What specific questions would you like answered that would help you better meet this child’s
developmental and educational needs?
1) ________________________________________________________________________
2) ________________________________________________________________________
3) ________________________________________________________________________
Please describe the child’s strengths:
Please describe any areas of functioning that need the most improvement:
Any other specific concerns you have about this child?
Besides English, are there any other languages used in the child’s instruction?
Page 1 of 6
Has the child ever been evaluated for learning or academic problems? ☐Yes ☐No
If yes, when?______
Please send copies of previous testing results and copy of the current Individual
Educational Plan.
ACADEMIC PERFORMANCE: Please circle the appropriate number below.
Excellent
1. Reading decoding
2. Reading comprehension
3. Reading rate and fluency
4.Spelling accuracy
5.Mathematics concepts
6.Mathematics computation
7.Handwriting
8. Writing rate
1
1
1
1
1
1
1
1
Above
Average
2
2
2
2
2
2
2
2
Average
3
3
3
3
3
3
3
3
Somewhat
of a
problem
4
4
4
4
4
4
4
4
Problematic
5
5
5
5
5
5
5
5
9. Punctuation/grammar
1
2
3
4
5
10.Ability to express thoughts through writing
11.Gross motor skills
12.Fine motor skills (using pencil & scissors)
13.Overall school performance
1
1
1
1
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
CURRENT CLASSROOM BEHAVIOR: Please circle the appropriate number below.
Average
1
1
1
1
Above
average
2
2
2
2
3
3
3
3
Somewhat
of a
problem
4
4
4
4
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
4
4
4
4
4
4
4
Excellent
1. Understanding verbal instructions
2. Completing classroom assignments
3. Organizational skills
4. Getting homework to and from
school
5. Completing homework
6. Relationship with peers
7. Following directions
8. Disrupting class
9. Verbally participating in class
10. Written expression
11. Handwriting
Problematic
5
5
5
5
5
5
5
5
5
5
5
Page 2 of 6
LEARNING PROBLEMS: Circle the number that best describes the child’s learning
problems (I.e., above and beyond what would be expected for his or her developmental age)
over the past 6 months.
Never or
rarely
Occasionally
Often
Very
often
1. Has trouble learning new material in an appropriate time frame
for age and skills
2. Has little desire to master new skills
3. Unable to tell time, days of the week, months of the year
4. Can’t repeat information
0
1
2
3
0
0
0
1
1
1
2
2
2
3
3
3
5. Knows material one day; doesn’t know it the next
6. Has trouble holding several different things in mind while
working
7. Has trouble following multi-step directions
8. Has difficulty copying written material from blackboard
0
0
1
1
2
2
3
3
0
0
1
1
2
2
3
3
0
1
2
3
0
0
0
1
1
1
2
2
2
3
3
3
0
0
1
1
2
2
3
3
0
0
1
1
2
2
3
3
0
0
1
1
2
2
3
3
0
1
2
3
1
2
Office Use Only (Gen):
9. Difficulty orienting self (i.e., gets lost, can’t find way, or gets
turned around easily
10. Has poor spatial judgment and often bumps into things
11. Confuses directionality (up/down, left/right, over under)
12. Has poor spatial organization on paper (difficulty staying in
lines, maintain space between words, staying within page
margins)
13 .Mixes up capital and lower case letters when writing
14. Reverses letters and numbers
(1-8)___/8
Office Use Only (VSP):
15.Has trouble expressing words or events in correct order
16. Often mispronounces known or familiar words or uses wrong
word
17. Has trouble verbally expressing thoughts
18. Says things that have little or no connection to what others are
discussing
19. Has difficulty distinguishing long vowel sounds and short
vowel sounds
20. Depends on teacher or others for repetition of task instructions
(9-14)__/6
0
Office Use Only (Lang):
21. Displays poor word attack skills (can’t sound out words)
22. Puts wrong number of letters in words
23. Confuses consonant sounds, e.g.: d-b, d-t, m-n, p-b, f-v, s-z
24. Unable to keep place on page when reading
Office Use Only (R/W):
>4/8
>3/6
0
0
0
0
3

(15-20)__/6
1
1
1
1
(21-24)___/4
2
2
2
2
> 3/6
3
3
3
3

>2/4
CLASSROOM SETTING: Please check all that apply, and provide details.
Type of setting
 Mainstream
 Integrated
 Substantially
separate
Number of students
Number of instructors



1:1
1:1
1:1
Aide present for child?
 Shared

 Shared

 Shared

None
None
None
Page 3 of 6
GENERAL EDUCATION SETTING: Please list any specific curricula or instructional
methodologies used in the child’s general education setting, if applicable
Academic area
Methodology or curriculum
Reading/reading-related materials
Mathematics
Writing/written expression
Please list services child receives through IEP:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Page 4 of 6
CHILD’S BEHAVIORAL AND EMOTIONAL FUNCTIONING
Circle the number that best describes the child’s behavior OVER THE PAST 6 MONTHS
1. Fails to give close attention to detail or makes careless mistakes
(e.g. homework)
2. Has difficulty attending to what needs to be done
3. Does not seem to listen when spoken to directly
4. Does not follow through when given directions
5. Has difficulties organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks
7. Loses things necessary for tasks or activities (school assignments,
books, pencils, etc.)
8. Is easily distracted by noises or other things
9. Is forgetful in daily activities
Office Use Only (I)
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when he/she is supposed to stay in seat
12. Runs about or climbs too much when he/she is supposed to stay
seated
13. Has difficulty playing or starting quiet games
14. Is “on the go” or acts as if “driven by a motor”
15. Talks excessively
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his/her turn
18. Interrupts or bothers others when they are talking or playing
games
Office Use Only (H):
19. Loses temper
20. Actively disobeys or refuses to follow adult’s request or rules
21. Is angry or resentful
22. Is spiteful and vindictive
23. Bullies, threatens, or scares others
24. Initiates physical fights
25. Lies to obtain goods for favors or to avoid obligations (i.e., “cons”
others)
26. Is physically cruel to people
27. Has stolen items of nontrivial value
28. Deliberately destroys others’ property
Office Use Only (ODD/CD)
29. Is fearful, anxious, or worried
30. Appears self-conscious or easily embarrassed
31. Appears afraid to try new things for fear of making mistakes
32. Feels worthless or inferior
33. Blames self for problems, feels guilty
34. Feels lonely, unwanted, or unloved; complains that “no one loves
me”
35. Appears sad, unhappy, or depressed
Office Use Only (Anx/Dep)
Never or
Rarely
0
Occasionally
Often
Very Often
1
2
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
0
1
1
2
2
3
3
(1-9)___/9
> 6/9
SUBTOTAL: _______
0
0
0
1
1
1
2
2
2
3
3
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
(10-18) ___/9
> 6/9
SUBTOTAL:______
0
0
0
0
0
0
0
1
1
1
1
1
1
1
2
2
2
2
2
2
2
3
3
3
3
3
3
3
0
0
0
1
1
1
2
2
2
3
3
3
0
0
0
0
0
0
1
1
1
1
1
1
2
2
2
2
2
2
0
1
2
(19-28)/10
(29-35) __/7
> 3/10
3
3
3
3
3
3
3

> 3/7
Page 5 of 6
36. Skips school without permission
37. Has set fires on purpose to cause damage
38. Destroys other’s property on purpose
39. Has broken into someone else’s home, business or car
40. Has said things like “I wish I were dead” or has tried to hurt self
41. Has distinct periods where mood is unusually irritable or unusually
good, cheerful, or high which is clearly excessive or different from
normal mood
42. Seems to have compulsions (repetitive behaviors that this child
seems driven to carry out, such as repeated hand washing, counting,
or erasing until holes appear)
43. Has prolonged temper tantrums (greater than 20-30 minutes)
44. Seems unaware of other’ existence, is uninterested in interacting
with others
45. Has odd, eccentric, or unusual preoccupations (e.g., clothing
items, toys, neatness)
46. Appears uninterested in activities children his or her age usually
like or participate in
Office Use Only (MH):
Never or
Rarely
0
0
0
0
0
0
Occasionally
Often
Very Often
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
0
1
2
3
0
0
1
1
2
2
3
3
0
1
2
3
0
1
2
3
(35-46) ___/11

>/11
Please describe this child’s personality—moods, behavior, emotional functioning, etc.
Please describe this child’s relationship with peers.
Is there any other information you think would be helpful for evaluating this child?
___________________
Teacher Sign
_____________________
Print
_________________________
Date Completed
____________________
Relationship to Patient
Please send completed packet to:
Developmental Medicine Clinic
1600 7th Avenue South
Dearth Tower, Suite 5602
Birmingham, AL 35233
Fax: (205)212-2994
Page 6 of 6