Get documents about "DBS Scoring Template
Document Sample
1
Developmental, Learning and Behavioral Screen
Child’s Name/Age: Form Completed By:
Date Completed: Relationship to Child:
1. When were you first concerned about your child’s development, learning or behavior? (child’s age):
2. Do you believe your child was slow in motor development? (learning to sit up, walk, run, etc):
3. Rate your child’s coordination in the following areas:
Good Average Poor
Walking ____________ ____________ _____________
Running ____________ ____________ _____________
Tying shoelaces ____________ ____________ _____________
Buttoning ____________ ____________ _____________
Catching ____________ ____________ _____________
Throwing ____________ ____________ _____________
Athletic abilities ____________ ____________ _____________
Handwriting ____________ ____________ _____________
4. Do you believe your child was slow in speech or language development? If yes, why?:
5. Is speech now adequate for age?
6. Has your child ever had speech or language therapy?
7. Is your child currently having problems at: ( ) home ( ) school ( ) both ( ) neither
8. Does your child have any of the following habits or problems?
( ) movements or tics ( ) head banging ( ) bowel problems
( ) nail biting ( ) bedwetting ( ) headaches
( ) thumbsucking ( ) soiling of underpants ( ) stomachaches
( ) eye blinking ( ) vomiting or nausea ( ) other aches or pains
( ) problems with eating ( ) problems with sleeping ( ) other; please indicate
( ) no significant habits or problems
9. Rate your child with regard to school experience (learning and/or adjustment):
Good Average Poor
a) Nursery school ____________ ____________ _____________
b) Kindergarten ____________ ____________ _____________
c) Previous grades ____________ ____________ _____________
d) Current grade ____________ ____________ _____________
2
10. Has the school complained to you about your child’s performance? ( ) Yes ( ) No
11. Is your child receiving special education help?
( ) full-time special class (type: ) ( ) other help (type: )
( ) full-time remediation or resource ( ) no special help
( ) out of school tutoring
12. Has your child had psychological or educational testing? ( ) Yes ( ) No
By whom? Results:
13. Has your child been seen by a professional person because of developmental, learning, or behavioral problems? ( ) Yes ( ) No
By whom? Results:
14. Has medication ever been given to your child to help with a behavior problem? ( ) Yes ( ) No
NAME OF DRUG DOSAGE DATES STARTED/STOPPED
1. __________________ _______________________________ ___________________
2. __________________ _______________________________ ___________________
3. __________________ _______________________________ ___________________
15. Does anyone else in the family have problems with development, learning, or behavior?
16. What do you think is causing the problems in your child?
Check () the column that best describes your child. Please write DK next to any items for which you don’t know the answer.
Not at Just a Pretty Very
Question Set One—ADHD-I All Little Much Much
1. Is often easily distracted by extraneous stimuli
2. Often does not seem to listen when spoken to directly
3. Often fails to give close attention to details or makes careless mistakes in school work,
work, or other activities
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or
duties in the workplace (not due to oppositional behavior or failure to understand
instructions)
5. Often has difficulty sustaining attention in tasks or play activities
6. Often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils,
books, or tools)
7. Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
(such as school or homework)
8. Often has difficulty organizing tasks and activities
9. Often shifts from one uncompleted activity to another
10. Is often forgetful in daily activities
3
Not at Just a Pretty Very
Question Set Two—ADHD-H All Little Much Much
11. Often interrupts or intrudes on others (e.g. butts into conversations or games)
12. Often engages in physically dangerous activities without considering possible
consequences (not for the purpose of thrill-seeking) e.g., runs into street without looking
13. Often talks excessively
14. Often fidgets with hands or feet or squirms in seat
15. Often blurts out answers before questions have been completed
16. Often has difficulty playing or engaging in leisure activities quietly
17. Often leaves seat in classroom or in other situations in which remaining seated is expected
18. Often has difficulty awaiting turn
19. Is often “on the go” or often acts as if “driven by a motor”
20. Often runs about or climbs excessively in situation in which it is inappropriate (in
adolescents or adults, may be limited to subjective feelings of restlessness)
Question Set Three—ODD
21. Often argues with adults
22. Is often spiteful or vindictive
23. Often blames others for his or her mistakes or misbehavior
24. Often actively defies or refuses to comply with adults’ requests or rules
25. Is often angry and resentful
26. Is often touchy or easily annoyed by others
27. Often loses temper
28. Often swears or uses obscene language
29. Often deliberately annoys people
Question Set Four—CD
30. Often initiates physical fights with other members of his or her household
31. Often initiates physical fights with others who do not live in his or her household (e.g.,
peers at school or in the neighborhood)
32. Has been physically cruel to people
33. Has forced someone into sexual activity
34. Often bullies, threatens, or intimidates others
35. Has been physically cruel to animals
36. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed
robbery)
37. Has used a weapon that can cause serious physical harm to others (e.g., bat, brick, broken
bottle, knife, gun)
38. Has deliberately destroyed others’ property (other than by fire setting)
39. Has deliberately engaged in fire setting with the intention of causing serious damage
40. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
41. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but
without breaking and entering, forgery)
42. Has broken into someone else’s house, building, or car
43. Has run away from home overnight at least twice while living in parental or parental
surrogate home (or once without returning for a lengthy period)
44. Often truant from school, beginning before age 13 years
45. Often stays out at night despite parental prohibitions, beginning before age 13 years
4
Not at Just a Pretty Very
Question Set Five—SOC All Little Much Much
46. Is able to verbally communicate clearly and connectedly (able to tell a story from
beginning to end without rambling or shifting topics)
47. Non-verbal communication skills are accurate ( facial expression matches their immediate
emotions, can interpret non-verbal communication from others)
48. Is able to follow group norms and social rules (behaves properly in structured situations,
follows rules when involved in games)
49. Is able to make new friends easily
50. Goes into new situations with confidence (doesn’t hesitate trying something new, looks
forward to social gatherings)
Question Set Six—EC
51. Basically an unhappy child
52. Often difficult to comfort as a baby
53. Exhibited irregular sleeping habits as a baby (walked/talked in sleep)
54. Threw tantrums when exposed to new situations as a baby
55. Rocked or banged the crib
Question Set Seven—DEP
56. Does your child seem sad
57. Does your child complain of being tired
58. Has your child had a change in appetite
59. Does your child talk of being worthless
60. Has your child had a recent change in weight
61. Has your child, when calm, ever said they wished they were dead
62. Has your child lost interest or pleasure in activities they normally enjoy
63. Had your child had trouble sleeping
64. Has your child ever tried to hurt themselves
For physician or designate use only. Please do not write in the area below.
Evaluation given to child’s teacher(s)? ( ) Yes ( ) No Number given:
Hearing test administered? ( ) Passed ( ) Failed Visual Acuity Measured _______Left ________Right
Overall Impression:
Initial Plan:
Additional Comments:
Created by Jeff Mann, D.O. and Brian McClune, D.O., March 1999
Related docs
