OISE Psychology Clinic

ADULT ASSESSMENT HISTORY

Client’s Name:______Clinician’s Name:______Date:______

Documents to include in file (if available):

  • Elementary/middle/high school transcripts
  • Previous assessment reports
  • Previous educational documents (e.g., IPRC, IEP)
  • Post-secondary transcripts and list of currently registered courses (if a student)

GENERAL

  1. What brought you in to do an assessment? (Probe as necessary for “the first clue that there might be a difficulty”, when it first started, symptoms, severity, duration)

  1. What previous interventions have you tried? What was the outcome? (Probe to get an understanding of anything that helped or made the situation worse).

  1. Have you had any previous testing? What was the outcome? Did you receive any accommodation based on it? Please describe.

LANGUAGE AND DEVELOPMENTAL HISTORY

EARLY YEARS

Note: Clarify if answer is No or Unknown. Ask for more details.

  1. Were you born prematurely? Yes No Unknown
  1. Did you have low birth weight? Yes No Unknown
  1. Tell me about any birth or pregnancy complications that you are aware of:

______

______

______

  1. Review any areas development difficulties from infant until pre-school. (Probe separation, divorce, separation anxiety, illness)

______

______

______

  1. Describe your language development ______

______

  1. What language was spoken at home? ______
  1. Did you have any difficulty learning to talk? Yes No  Unknown

Describe:______

  1. Did you receive any Speech and Language Assessment or Therapy Yes No  Unknown

Describe:______

  1. Did you attend pre-school or an early education program? (Probe for any developmental anomalies)

______

______

  1. Tell me about any difficulties you experienced in your early language and motor development:

______

______

______

SCHOOL HISTORY

  1. How many schools did you attend?
  1. What was the reasons for changing schools?______
  1. Did you have frequent or extended absences from school?______
  1. Did anyone tell you that you had behavioural problems?______
  1. Did you receive any special education/remediation/resource assistance/specialized tutoring?
  1. What grades or courses (if any) did you repeat?______
  1. Were you ever diagnosed with a disability or disorder which explained why you had trouble learning? If so, what?

ELEMENTARY SCHOOL (K-8)

  1. Describe your early classroom experience______

______

______

  1. Review any problems learning in school. (Probe for tutors, special classes, special education. When did they start and for how long).

______

______

HIGH SCHOOL (9-12)

  1. Where did you go to high school?______
  1. What was the primary language?______
  1. Was it a private school?______
  1. What languages did you learn?______
  1. What were your best subjects throughout high school?______
  1. What were your worst subjects?______
  1. Did you ever receive any help (remediation) in elementary or high school?______

If Yes, when?______

If Yes, what type of help did you get?______

  1. What were your strengths in school aside from grades?______

______

  1. Did you have any challenges that stand out to you i.e. ways you felt different from your peers? (Probe: pace, presentation, essays)______

______

  1. Describe any behavioural problems in or outside of school______

______

  1. Was school generally a positive or negative experience?______
  1. What was school like for you socially? What kind of social network did you have?______

______

  1. Did you do homework? If so, did you do it on your own? Who helped you?______

______

  1. List any grades or courses failed in elementary or high school______
  1. Did you miss a lot of high school? If so, when and why?______

______

  1. What extra-curricular activities did you do?______

______

  1. How did handle school transitions? Please describe.______

______

POST SECONDARY EDUCATION

  1. List any post-secondary courses you have taken or are taking and the marks received:______

______

______

  1. List any problems you are having in school now?______

______

  1. How have you tried to reduce these difficulties? How successful were these efforts?______

______

ACADEMICS

What type of method best suits your learning style (i.e. visual, auditory, experiential)?______

______

1.Reading

Do you think your reading speed is slow, fast, or average?______

Do you misread words?______How often?______

Do you have problems understanding what you read?______

Do you lose your place when reading or use your finger/marker to help keep your place?______

How long can you sit and read at one time?______

2. Writing

Do you have problems expressing yourself in writing?______

Do you have difficulty organizing your writing?______

Do you ever miswrite words?______

Do you ever forget to write word endings, verbs, etc.?______

Do you have problems with grammer?______

Do you have problems spelling?______

3. Speaking

Do you have difficulties expressing yourself verbally?______

Do you prefer written or verbal expression?______

Do you ever mispronounce words (give examples)?______

What languages do you speak?______

What was the first language that you learned to speak at home?______

If English is NOT your first language, at what age did you learn English?______

Describe any problems you had in learning English______

______

Describe any learning problems you had (have) in non-English language(s)______

______

4. Hearing

Do you ever mishear words, or mix up words that sound the same?______

If yes, give examples______

Do you have problems listening and writing at the same time?______

5. Math

How are you at Arithmetic?______

Do you know your times tables?______

Do you ever misread/miswrite numbers?______

Do you have trouble making change at stores?______

6. Memory

Did you have problems with memory in school?______

If everyday life?______

What is your memory like for names?______

Memory for faces?______

7. Other

Are you comfortable using a computer? (If not, why?)______

______

Describe your usual approach to studying, including time spent:______

______

ORGANIZATION AND TIME MANAGEMENT

How well do you organize and budget your time?______

______

______

EMPLOYMENT HISTORY

Describe your employment history.

Company / Role / Responsibilities / Length of Role / Reason for leaving (voluntary/involuntary)

What did you like about your jobs?______

______

What did you dislike about your jobs?______

______

Did you have any accommodations?______

______

LATERALITY

  1. Are you right or left handed?______
  1. Do you do everything with that hand?______
  1. Did you always use that hand?______

SPATIAL SKILLS

  1. Do you frequently get lost?______
  1. Do you have a good sense of direction?______
  1. Are you good at picturing something in your mind?______
  1. Can you understand maps, charts, diagrams?______
  1. Do you have any problems with fine motor co-ordination (e.g. threading a needle, using keys/tools)?

______

  1. What is your handwriting like (i.e. neat/sloppy, fast/slow)?______

ATTNTION AND CONCENTRATION

  1. Do you have any problems paying attention to something or concentrating?______

If Yes, explain (give examples) and go on to the following questions.______

______

  1. How old were you when problems with attention began?______
  1. Have you ever been diagnosed with Attention Deficit Disorder?______

When?______By whom?______

  1. Have you ever taken medication(s) for attention problems (specify)?______

______

HYPERACTIVITY AND IMPULSIVITY

  1. Do you or others think that you are hyperactive at present?______

What about as a child?______

  1. Do you have problems being impulsive (e.g. acting or making decisions too quickly, being interruptive, being impatient while wating)?______

What about as a child?______

  1. Have you been in trouble with the law?______

MEDICAL HISTORY

  1. To the best of your knowledge, did your mother experience any problems during her pregnancy with you (e.g. accident, illness)?______

If Yes, explain______

  1. What did you weigh at birth?______
  1. As a child, did you ever experience anything other than the normal childhood illness (e.g. did you ever have seizures, very high fever for a long time, polio, etc.)?______

If Yes, what?______

  1. Have you ever had a severe head injury or lost consciousness?______

If Yes, when and how long?______

______

  1. List any allergies or medical conditions from which you presently suffer:______

______

  1. If you are taking medication(s), please give the name(s), dosage, and reason for taking:______

______

______

  1. Do you have any vision problems?______

Hearing problems?______

If Yes, do you need to use corrective lenses or a hearing aid?______

PERSONAL AND SOCIAL

  1. Describe use of alcohol and “street” drugs:______

Has your pattern of drinking or drug use changed?______How?______

______

  1. Have you ever experienced emotional or psychological difficulties (e.g. depression, anxiety)?______

If Yes, specify:______

Did you get treatment? If Yes, specify______

  1. Are you having any difficulties with stress, anxiety, depression, or other problem(s) now? Specify______

______

______

______

  1. Do you have any difficulties with peer and/or intimate relationships? Specify______

______

______

  1. Do you feel that your learning problems have an impact on your relationships (i.e. understanding the use of humour, sarcasm, social convention)? If yes, specify______

______

______

  1. What are your hobbies?______

______

  1. What are your future plans or goals?______

______

______

  1. How are you hoping to use the information from the assessment?______

______

FAMILY INFORMATION

  1. Parents’ occupations:______
  1. Parents’ education:______
  1. Siblings:

Age:______Education:______

Age:______Education:______

Age:______Education:______

Age:______Education:______

Age:______Education:______

  1. Specify if anybody in your family ever had problems with schoolwork (e.g. reading, writing, spelling, arithmetic, etc.).______

______

Did they ever receive any special help?______

______

  1. Has anybody in your family every experienced emotional or psychological difficulties (e.g. depression, anxiety) which required treatment? If yes, specify______

______

______

______

  1. How would you describe growing up in your family?______

______

______

  1. What was your family’s attitude toward school and learning?______

______

______

  1. What are your relationships like with your family now?______

______

______

______

GENERAL INFORMATION

  1. Current status:  Single  Married  Divorced
  1. Do you have any children? ______If Yes, how many?______
  1. Does any of your children have problems with school?______

______

  1. What is your current living situation?______

______

  1. Is there anything unusual or stressful that would be important for us to know?______

______

______

______

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Client File #______

Page 1 of 12 Updated September 2016