Services

Initial Evaluation Questionnaire for ADHD Assessment

ADHD Testing at Forest Lane Pediatrics of Plano and Dallas

Thank you for allowing us to participate in assessing your child’s educational needs. We know that your child’s emotional and educational well-being is important to you as a family. In order to make your visit with the doctor productive, please provide us with the items below and complete the questionnaire fully. A staff member will contact you once all appropriate documents are received. The providers also will need to examine your child prior to prescribing any medication. If you wish to meet with the doctor privately, please discuss with the scheduler when making this appointment.

Please download this Initial Evaluation Questionnaire for ADHD Assessment, sign, and submit with the following forms:

  1. ADHD Controlled Substance Policy (PDF) Download
  2. Vanderbilt ADHD Assessment – Teacher (PDF) Download
  3. Vanderbilt ADHD Assessment – Parent (Prefer that each parent complete the form) (PDF) Download
  4. Recent report card
  5. Any previous evaluations of your child’s learning (school IEP, psycho-educational testing, IQ testing, standardized test)

Please submit paperwork listed above. A staff member will contact you to schedule an appointment once the doctor has a chance to review the documents.

ADHD Resources and Frequently Asked Questions

Initial Evaluation Questionnaire for ADHD Assessment

Initial Evaluation Questionnaire for ADHD Assessment (PDF) Download

Concerns: (Please tell us what brings in for evaluation):

School 

Grade:
Name of school:
When does school start and end? AM ______________   PM _______________
Which subjects are difficult for you?
How many years have you had trouble with school?
Have you ever had to repeat a grade and which grade?  No___ Yes____
Which grade?
Have you had any previous educational evaluation at school or with a psychologist?
When:
Who:

*Please provide any documentation from this visit

Does she or he receive any special tutoring or accommodations at the school?
No___ Yes___
If Yes:

Appetite

Who you classify your child as a __good eater /___picky eater?
Does he or she take a daily vitamin? No___ Yes___
What if any special diets have you tried?

Sleep

What time is bedtime?
What time do you wake up each morning?
Problems with sleep (falling asleep, waking up, snoring):
Explain:

Development

Was your child premature infant? No____ Yes____
If yes: How many weeks?
Problems during the pregnancy?

Any problems in the nursery or first month of life?

Were there any concerns with development before kindergarten? No___ Yes____
If yes:

Family

Any major changes at home during the past year (i.e. death in the family, changing schools, etc)?:  No___ Yes___
If yes:

Past Heart History

Any history of passing out, racing heart beat, skipped heart beats, or heart problems?
No___ Yes____
Explain:

Any family history of sudden unexplained death, heart problems at a young age, or irregular heart beats (arrhythmias)?
If yes, who and what condition?