Interview Questions
Patient Name:
Who is answering these questions:
Date:
When answering these questions, please provide some examples when appropriate. If a known brain injury has occurred, please answer the questions by listing responses as before injury and after when appropriate. Your responses will be summarized in the report.
1. Describe why you are requesting this Assessment: (include examples of the problem)
Has the child been tested before? If so, when? Please provide a copy of the test results.
How long have the problems been going on.
When did you start noticing them.
What situations do you notice the problem? (Home, school Etc.)
Is there anything that you have noticed that triggers the problem?
What effect has the problem had on daily life at home, school, social etc?
How aware is the child of the problem? How do they react to the problem?
How do they cope with their symptoms?
What do you think may be causing the problem?
What have you done to resolve the problem so far, if anything?
If you have tried things, what has worked and what hasn’t?
2. Developmental History
Anything remarkable about Pregnancy?
Describe Labor and Delivery
Apgar Scores- normal or list problems
Milestones: (give approximate age)
Sitting:
Walking:
Crawling:
Talking:
Potty Training:
Last time wet the bed:
Any interesting things I should know about regarding their developmental progress?
3. Health (If current symptoms and past are different (ie due to a brain injury) please specify).
Describe history such as ear infections, surgeries, broken bones, head injuries, concussions, seizures, chronic problems (diabetes, etc.), stitches, etc.
Current physical complaints (headaches, stomachaches, dizziness, always cold or hot, etc.) and frequency and how long has this been going on.
Current Medications if any:
Approximately when was last physical including eyes and hearing checked
Please describe any occupational therapy, vision therapy, auditory therapy or any other sensory or physical therapy not mentioned here:
Please describe any other medical doctors that are involved with your child, dates you have seen them, reasons for seeing them, treatment involved and results.
Family mental health history along with physical health issues (learning disabilities, emotional issues, immunological diseases, diabetes, thyroid, etc.)
Any history or current speech problems? If so what kind and what was done about it.
Current appetite: Lower or higher appetite?
Craving carbs, sugar, etc.?
Healthy diet?
Vitamins?
Current Sleeping (troubles waking up and/or falling asleep, gets up often middle of night, sleeps in parents room, naps, nightmares, etc.)
Does your child snore?
Current Energy Level:
Sensory Issues (sensitivity to certain fabrics, tags, textures, tastes, noises, light etc.)
Motion Sickness:
Hand Dominance: Right or Left. Any problems determining which hand was dominant? Any difficulty with learning where right and left is?
Describe physical coordination skills, balance problems- I.E. Clumsy, trouble doing sports, trouble learning to ride a bicycle, etc.
Any difficulty with fine motor skills- I.E tying shoe laces, poor handwriting, etc.
Describe any problems with hygiene and self-care:
Describe any signs of puberty (menstruation, etc.)
Any exposure to cigarettes, alcohol, drugs?
4. Education (If current symptoms and past are different (ie due to a brain injury) please specify).
How long at current school? If changed, how did they respond to the change?
How old were they when they learned to read?
Any struggles with it?
What is current and history of grades:
What subject are they good at and not so good at?
Which (if any) subjects have been difficult for them consistently throughout their academic years?
What attitude and/or approach does your child have to their homework? (seems to take too long, rushes through, has missing assignments, etc.)
Does the child like school?
What do the teachers/principals have to say about them?
Any behavioral problems in school? If so, describe them and what has been done about them so far.
What has been done at school to accommodate behavior and or cognitive problems in school and/or at home? (504 or IEP)
5. Cognitive Functioning (If current symptoms and past are different (ie due to a brain injury) please specify).
-Memory:
-Attention:
-Planning/Organizing:
-Motivation (in school or home):
-Judgment:
-Risk Taker:
-Creativity:
-Sense of Humor:
6. Emotional Functioning (If current symptoms and past are different (ie due to a brain injury) please specify).
Describe Emotional Disposition
Describe the following:
-temperament (laid back, fussy, etc.) as a baby and current temperament/personality (outgoing, quiet, anxious, type A, etc.)
-Ability to be soothed (took forever for baby to calm down, or calmed down immediately, etc.) hard to calm down now
-Describe early communication skills (i.e. watching and imitating, ability to demonstrate and react to facial expressions)
-Describe ability to play imaginatively
-Discuss any separation anxiety with baby sitters, going to school, etc.
-How did they transition to any new siblings
-Tantrums? If so, describe behavior and how long it lasts:
-Sensitivity (i.e. do they cry easily, etc.)
-What makes them angry and how do they respond?
-Describe high or low frustration tolerance:
-Describe any signs of perfectionism, obsessions, and rituals:
-How often are they anxious, how do they act when anxious, what makes them anxious.
-Describe any fears:
-Moodiness (what is their overall mood like-sad, even, happy? Also, how often does the mood fluctuate? Do they go through periods where they seem too happy?)
-Any history of abuse? (verbal, physical, sexual)
-Any suicidal ideation? If so, give specific examples and how this has been handled.
-Any behavioral problems involving violence?
-Any behavioral problems involving the law?
-Any concerns with possible auditory or visual hallucinations?
-Any other special behaviors I should know about?
Please describe any crisis or losses in their lifetime and how they handled it (death of loved one, death of pet, move to new school, divorce, etc.)
Have there been any mental health treatment and or assessment in the past?
When, where and for how long?
What was the reason for treatment?
What was the outcome?
What did they like and dislike about it?
Who is in family and who lives in the home? How long have they lived in home?
Any pets? How are the pets treated?
Any divorce? If so, describe parent’s relationships, custody arrangements, how long divorced, how child is adjusting.
Describe the relationships the patient has with each family member:
What does the child do to get disciplined:
What discipline is used and how long is punishment?
How does the child react to it? (Angry, remorseful, etc.)
Is the discipline effective?
Involvement with religion:
What does the child do in leisure time?
What are their interests and hobbies?
What, if any extracurricular activities are they involved in?
Any career aspirations yet? If so, what are they interested in.
Any work experiences? Describe where, length, relates to others, success and failures.
How long parents married and if applicable how long divorced?
Describe how child might perceive the marital/divorce relationship:
Parents education and careers? Any problems in school?
Any current stressors in the marital/partner relationship?
Current individual stressors outside of the relationship? (ie financial problems, extended family illnesses, etc.)
7. Social Functioning (If current symptoms and past are different (ie due to a brain injury) please specify).
Social Skills-describe friendships and long-term friendships
How they interact with others?
What is their desire to socialize?
Describe any problems with friends
Describe any challenges with reading social cues
8. General
Describe your child’s overall strengths and weaknesses:
What do you expect and or hope to gain from this evaluation and how do you think it will help your child.
What will you tell the child why they are being tested?
Is there anything else you feel I should know about your child?