Diagnostic Interview for Adults



Turning Point Assessment Services

_____________________________________________________________

Patty Martens, MA, Case Coordinator/Consultant 720-237-9059

1546 Williams Street iqtestingdenver@

Denver, CO 80218

Diagnostic Questionnaire

This questionnaire is for the purpose of helping me understand you better. I will use the information to interpret test results and write your final report. The benefit of providing background information is that your assessment will be more complete and personalized to your needs. Please let me know if there is any information you want me to know but do not want written into your report. If you have any questions we can discuss them at the time of your assessment. Please use additional paper if you need it. If you would like to wait until the time of your assessment we can go over this questionnaire and fill it out together.

Today’s Date:

Name:

Primary Address:

Home Phone#:

Cell/Work#:

Date of Birth:

Email address:

1. What do you hope to learn from this assessment:

2. Basic Personal Information:

Where are you currently residing?

Are you single, married, divorced or separated?

Do you have any children? If so, what are their ages?

3. Family History:

Where were you born and raised?

How often did you move between the ages of birth and 18 years?

How many siblings do you have and what is your birth order?

What is the incidence of learning, psychiatric, significant medical or attention deficit problems in your family?

Are you bilingual or from a bilingual family and if so, what languages do you or your family speak?

4. Health History

Were you born healthy?

Were there any complications with your birth?

Did you develop any milestones early or late such as walking, talking, bike riding, reading or writing?

Have you had any significant accidents or illnesses? Head injuries and/or ear infections are especially important to report.

Do you have and vision or hearing problems and if so how are they corrected?

Do you have any significant health conditions? If so, do you require ongoing medication? What side effects from medication have you experienced? Examples: ADHD, diabetes, hyperthyroid, arthritis, asthma.

Do you have a history of alcohol or drug abuse? If so, please explain.

5. Educational History

How many schools did you attend from Kindergarten to college. Please indicate if the schools were public or private and include the names of the schools and dates attended.

Describe your school experience (grades, disciplinary actions, challenges, accomplishments, GPA, etc.)

Were you diagnosed with specific learning disabilities or ADHD as a child or teen? If so, what grade were you in when diagnosed and what area of learning was involved? Examples: paying attention in class, Dyslexia, reading problems, writing problems, math problems.

What kind of help did you receive for your disability and how did it help you?

6. Employment History

What jobs have you had? List them in order and briefly describe your experience as positive or negative.

What are your career goals?

7. Social History

What are your special interests or passions?

Do you have a history of significant psychiatric illnesses such as depression, anxiety, mood disorder? If so, briefly explain and include any medication or treatment you are/were receiving?

8. Functional Limitations Self-Report

To the best of your ability, please give examples of learning or attention problems that limit you in the areas listed below. You can type your answers in the third column. We will discuss these examples further during your appointment, so it’s okay to be brief. Examples might include work, home, community, family and/or social experiences.

|Functional Capacity |Examples |Examples of limitations you experience |

|Interpersonal Skills: The ability|*Conflict with friends and/or family due to school or | |

|to establish and maintain |employment setbacks. | |

|positive personal, family and |*Moodiness due to low self-esteem and lack of | |

|community relationships. |confidence in your ability to do things independently | |

| |or accurately. | |

| |*Conflict with employers or work-mates due to learning| |

| |or attention problems. | |

| |*Others underestimating your ability because of memory| |

| |problems or other learning/attention issues. | |

| |*Others don’t take you seriously. | |

|Self-Direction: The ability to |*Starting toward a goal with enthusiasm and quickly | |

|set goals, work toward goals or |giving up due to repeated failure in a certain area | |

|reach goals without help from |*Setting goals that others tell you are unreachable | |

|others. The ability to start a |and impossible to achieve. | |

|task and see it through without |*Not setting goals and having no vision of the future.| |

|help. |*Fear of being independent and feeling like you cannot| |

| |do things without help. | |

| |*Chronically late for work or class. | |

|Communication: The ability to |*Numerous mistakes in emails, texts and written notes | |

|exchange and receive information.|to the extent that others comment on the inability to | |

| |read them. | |

| |*Fear of making phone calls to set up job interviews | |

| |or inquire about jobs. | |

| |*Not listening while others are talking. | |

| |*Not understanding or misunderstanding what people are| |

| |saying. | |

| |*Others telling you that they don’t understand what | |

| |you’re trying to say. | |

| |*Not communicating thoughts or feelings due to fear of| |

| |miscommunication. | |

| |*Unable to read emails or text messages or letters | |

| |accurately. | |

|Work Tolerance: The capacity to |*Taking incompletes or failing in classes due to | |

|meet the physical and |procrastination, anxiety or depression. | |

|psychological demands of work or |*Failure to keep up with the pace of the class or a | |

|school. |job. | |

| |*Inability to complete a test or job task within a | |

| |time limit or deadline. | |

| |*Inability to perform physical tasks at a job or in a | |

| |class. | |

| |*Problems with time management or organization. | |

| |*Unable to find things I need like car keys, cell | |

| |phone, glasses. | |

|Mobility: The physical and |*Not learning to drive. | |

|psychological ability to move |*Loss of driver’s license due to neglecting tickets or| |

|from place to place inside and |speeding. | |

|outside the home. |*Inability to use mass transportation due to getting | |

| |lost or misreading schedules. | |

|Motor Skills: The purposeful |*Poor or illegible handwriting. | |

|movement and control of the body |*Inability to ride a bike. | |

|and its members to achieve |*Stumbling or falling frequently because of impulsive | |

|results. |actions or not watching where you’re going. | |

| |*Poor coordination causes you to avoid certain | |

| |physical activities. | |

|Work Skills: The capacity to |*Leaving a job or changing a class due to a | |

|learn and perform job tasks or |realization that it is too challenging. | |

|school tasks. |*Failure to keep a job due to memory errors or | |

| |overlooking important details. | |

| |*Misreading directions on a test or the contents of a | |

| |book. | |

| |*Inability to take notes that can be relied on as | |

| |accurate or legible. | |

| |* Unable to work in retail stores because of problems | |

| |with math and understanding money. | |

| |* Being fired from an office job because of problems | |

| |staying focused on the paperwork. | |

| |*Not meeting deadlines. | |

| |*Inability to sustain attention when studying. | |

9. Is there anything else you would like me to know about your history?

*Reminder: Please make a note or leave out any information you do not want included in the background summary*

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