|
FB Evaluation
|
Follow up visit
|
|
Chief Complaint
|
|
|
Vanderbilt Assessment completed
|
Completed By
• • •
|
|
Vanderbilt Comments
|
Cogmed Training:
|
|
Quotient Test completed:
|
Quotient Test Attention:
|
|
Quotient Test Motion:
|
Quotient Test Global:
|
|
Hearing Exam:
• • •
|
Last eye exam:
|
|
Pediatric Symptom Checklist-17 (PSC-17)
|
|
|
1. Fidgety, unable to sit still
• • •
|
2. Feels sad, unhappy
• • •
|
|
3. Daydreams too much
• • •
|
4. Refuses to share
• • •
|
|
5. Does not understand other people's feelings
• • •
|
6. Feels hopeless
• • •
|
|
7. Has trouble concentrating
• • •
|
8. Fights with other children
• • •
|
|
9. Is down on him or herself
• • •
|
10. Blames others for his or her troubles
• • •
|
|
11. Seems to be having less fun
• • •
|
12. Does not listen to rules
• • •
|
|
13. Acts as if driven by a motor
• • •
|
14. Teases others
• • •
|
|
15. Worries a lot
• • •
|
16. Takes things that doesn't belong to s/he
• • •
|
|
17. Distracted easily
• • •
|
|
|
PSC-17 - I ≥ 5:
|
PSC-17 - A ≥ 7:
|
|
PSC-17 - E ≥ 7:
|
Total Score ≥ 15
|
|
Depression Scale for Children (CES-DC)
|
|
|
During the past week
|
Below is a list of ways you might feel or acted.
|
|
1. I was bothered by things that usually don't
• • •
|
2. I did not feel like eating, wasn't hungry
• • •
|
|
3. Not able to feel happy even when others tried
• • •
|
4. I felt I was just as good as other children
• • •
|
|
5. I felt like I wasn't able to pay attention
• • •
|
|
|
6. I felt down and unhappy
• • •
|
7. I felt like I was too tired to do things
• • •
|
|
8. I felt like something good was gonna happen
• • •
|
9. I felt like things I did before didn't work
• • •
|
|
10. I felt scared
• • •
|
|
|
11. I didn't sleep as well as I usually do
• • •
|
12. I was happy
• • •
|
|
13. I was more quiet than usual
• • •
|
14. I felt lonely, like I didn't have friends
• • •
|
|
15. I felt that kids were not as nice to me
• • •
|
|
|
16. I had a good time
• • •
|
17. I felt like crying
• • •
|
|
18. I felt sad
• • •
|
19. I felt people didn't like me
• • •
|
|
20. It was hard to get started doing things
• • •
|
|
|
Score >15:
|
|
|
Brigance Screening
|
Brigance Testing:
|
|
Brigance Score:
|
Brigance Cutoff:
|
|
Referred By:
|
Additional Screenings/Scores (i.e. ASQ-SE):
|
|
Recommendations:
|
Referred to:
|
|
Symptoms of hyperactivity
|
|
|
Described as "driven by a motor"
|
Difficulty engaging in quiet activities
|
|
Fidgety, unable to sit still
|
Unable to sit or remain seated
|
|
Restlessness
|
Runs around or climbs excessively
|
|
Talks excessively
|
Other:
|
|
Symptoms of impulsivity
|
|
|
Blurts out answers before question is done
|
Difficulty waiting for his/her turn
|
|
Interrupts or intrudes on others often
|
Other:
|
|
Symptoms of inattention
|
|
|
Avoids/dislikes mental tasks that require effort
|
Difficulty organizing tasks or activities
|
|
Difficulty sustaining attention in task or play
|
Does not seem to listen when directly spoken to
|
|
Easily distracted by extraneous stimuli
|
Is forgetful in daily activities
|
|
Loses important things needed for tasks
|
Makes careless mistakes in schoolwork, work
|
|
Does not follow through often
|
Other:
|
|
|
|
|
Severity:
• • •
|
Status:
• • •
|
|
Frequency:
• • •
|
Comments:
|
|
Behavioral HX:
|
|
|
Behaviors began before age 7 to some extent
|
Comments:
|
|
Known learning disability
|
Comments:
|
|
Pertinent past medical history
|
Please specify:
|
|
Behaviors create problems at home
|
Comments:
|
|
Behaviors create problems at work:
|
Comments:
|
|
Behaviors create problems at school:
|
Comments:
|
|
Behaviors create problems socially:
|
Please specify:
|
|
Behaviors have persisted for > 6 months
|
Comments:
|
|
Recent changes in home life:
|
Please specify:
|
|
Therapy/Counseling
|
Comments:
|
|
Lead exposure
|
Comments:
|
|
Prior diagnosis of ADD/ADHD
|
Comments:
|
