JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Preliminary Diagnostic Interview
If you are a parent, completing for a child, please enter the child's name and birthdate, but your address and email, and answer all questions about the child. Thank you! A copy of your completed form will be emailed to you.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Full Name of the subject of the Preliminary Diagnostic Interview:
*
Your answer
Birthdate of subject:
*
MM
/
DD
/
YYYY
Email:
*
Email where responses will be sent.
Your answer
Name of the person completing this Background Information Form
Your answer
Cell number or LAN:
*
Your answer
Full mailing address:
*
Your answer
HEALTH Current medications taken with reason for taking and dosage instructions, along with current medical conditions (diabetes, depression, anxiety, heart disease, etc. ) :
*
Your answer
Please describe any�vision, hearing, or other sensory problems (detail your history and treatment):
*
Your answer
Please describe development in early childhood (birth to age 6). Note any delays and interventions and the success of treatments:
*
Your answer
Please describe developmental and academic difficulties or delays that appeared in the elementary grades (1-8). Also describe interventions / treatments, and their success:
*
Your answer
Please describe any emotional, behavioral, and social problems and how they impacted the student across environments (home, school, socially). Also include details on the age of onset, treatment, and results:
*
Your answer
Please describe academic difficulties that appeared in the high school grades (9-12), interventions, and the success of interventions:
*
Your answer
Please describe any problems that appeared during the college or adult years (health, economic, social, emotional, etc.), interventions, and the success of those interventions:
*
Your answer
Please describe the reasons that you are seeking diagnostic testing, and what you hope the testing will accomplish:�
*
Your answer
FAMILY HISTORY Do you have family members with learning disabilities or other disorders that impair personal success? If yes, please elaborate:
*
Your answer
Please describe talents, strengths, and hobbies:
*
Your answer
Please describe weaknesses:
*
Your answer
Please describe goals for the immediate future. Include the name and location of schools, enrolled / future classes, majors and programs:
*
Your answer
Please describe subject's current occupation (student, job, community service, etc.):
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Dyscalculia.org.
Report Abuse
Forms
