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TEACHER QUESTIONNAIRE

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Dear Teacher,
I look forward to evaluating this student's cognitive/neurologic development as requested. Your answers on this questionnaire will help me understand this student's health, neurologic functioning, teaming skills, and behavior. Please list your concerns and provide all information you feel may be relevant. This student and his/her parents are being asked to fill out similar questionnaires.
Please send the completed questionnaire back to me at the following address as soon as you can.
Thank you very much for your time and concern.
Student Name
Age
School Name
Phone
School Address
Form Completed By:
Grade
# of Students
How much time does student spend in your class per week?
What Type of Class is it?
What are your concerns and questions about this student's learning, development, and/or behavior?
Please describe this student's strengths and weaknesses in the classroom.
Has this student had any previous evaluation? Could you provide the dates and results for me?
(List below or attach copies)
speech/language evaluation
achievement tests
IQ tests/psychological evaluation
psychiatric evaluation
neurologic evaluation
physical/occupational therapy evaluation
What services are available at your school?
help with writing vocational training/counseling
help with reading guidance counseling
help with mathematics group counseling
speech/language therapy psychological testing
PT/OT resource room/learning center
help with studies self-contained class for children with
learning problems    
Has this student ever received special services or been retained in a grade? Yes No
Please describe this student's current educational placement including class types, grade levels, and any special help he/she receives.
Please rate this student's skills in the following areas:
ACADEMIC PERFORMANCE:
  Weakness Compared To Others Average Strength Compared To Others
Speech/Language:      
Pronunciation
Stuttering
Understanding Others
Hearing/Listening
Other
Reading:
Aloud
Stormy
Reading Rate
R6COQfri1ion Of Words
ruij-n-Mrrf rnOmCS
Comprehending What Was Read
Remembering What Was Read
Spelling:      
Accuracy
Consistency
Writing:      
Legibility/ Coordination
Remembering Letter Shapes
Punctuation
Sentence Structure/ Organization
Sophistication Of Ideas
Mathematics:      
Understanding The Question
Remembering How To Do The Problem/Basic Skills
Word Problems/ Applications
History/Social Studies
Science
Foreign Language
Do you have other concerns about academic skills/development?
Feel free to explain any of your responses more fully
Please rate this student's skills in the following areas:
ACADEMIC PERFORMANCE:
  Weakness Compared To Others Average Strength Compared To Others
Note-Taking Skills:      
Rate/Keeping Up
Identifying Key Concepts
Concentration/Attention
  Weakness Compared To Other* AVVTBQtt Strength Compared To Others
Comprehension Of OaMy/AuraHy Presented Material
Comprehension Of Wrinan/Visualry Presented Material
Studytna:      
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Memorization
Organization
Allowing Appropriate Time
Concentration
Auf0miieftte
Attention To Instruction
Comprehension Of Task
Checking Work
Mowing Appropriate Time/Using Appropriate
Books And Supplies
Completion Of Task
Response To Feedback
Consistency Of Performance
Test Taking:      
Anxiety/Choking Up
Pacing/Organization
Recad Of Facts
Consistence Of Performance
Class Participation:      
Attention/Staying On Subject
Enthusiasm/Curiosity
Social Skite
Other
Talking In Class
Leaving Seat/Disruptive
Bothering Others
Athletic Ability
Imagination/Creativity
Sense Of Humor
Flexibility/Acceptance Of New Ideas
Do you have other concerns about study strategies/other characteristics? Yes No
Feel free to explain any of your responses more fully.
PERSONALITY/BEHAVIORAL HISTORY:
The following is a list of a wide variety of issues which may be of concern.
column for this student. 		Please check the appropriate
  Average For Age/Not A Problem More Than Average/ Somewhat Problematic Significant Problem Or Concern
Sadness/Depression
Anxiety/Worry
Low Self-Esteem/Confidence
Variable Moods
Easily Frustrated
Easily Angered/Irritable
Crying/Tantrums
Aggression/Fighting
  Average For Age/Not A
H*mlil«Mi
rTODWm
 More Than Average/ Somewhat
P JJlKi-l-H M.ttl-
r*rouiemaDC
 Significant Problem Or Concern
Defiance/Disobedience
Destructive Behavior
Truancy/Running Away
Lying Or Stealing
Refection By Peers/Unpopular
Gets Teased
Teases Others/Cruelly
teoiattorVLoneliness
Passive Behavior/Eager To Please
Shyness/Mistrust
Ctowning/AcCng Out/Disruptive
Pestan Others
Manipulative/Controlling
Frequent Pare/Physical Complaints
Accident Prone
Acts Without Thinking
Hurries Through Tasks
Short Attention Span
Misses Key information
Easily Distracted
Daydreams
Says irrelevant Things
Daytime Steepiness/Easilv Fatiqued
Easiiy Bored/Restless
Difficult To Safety
Fidgety/Overly Active
High Energy Level
Variable Performance (Unpredictable Quality Of Work/ Inconsistent Grades)
Eating Or Appetite Problems
Sleep Habits/Insomnia/Sleepwalks
Wets Or Soils
Head-Bangs/Other Self Injurious Behavior
Rocks/Other Repetitive Habits
Hordes Things
Repetitive Acts/Compulsions
Sees Or Hears Things That Are Not There
Uses Drugs Or Alcohol
Sudden Twitches/BKnks/Nods
Unusual Grunts Or Other Sounds
Difficulty Giving Or Receiving Affection
Inrtexfcte/Difreutty With Changes
Do you have any other concerns about personality, emotional, or behavioral functioning?. Yes No
Feel free to explain any of your responses more fully.
(Please also complete the attached EdeJbrock CAP questionnaire on attention issues.) Please provide any additional comments or information you feel may be helpful.
Please mail this back to me as soon as possible and thank you very much.


Carolyn E. Hart. M.D.
Robert A. Nahouraii, M.D.
Pediatric Neurology
Mecklenburg Neurological Associates
1900 Randolph Rd.. Suite 1010
Charlotte, NC 28207
(704)334-7311
   

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