BDx Norming Intake Form

GENERAL INSTRUCTIONS
FOR COMPLETING THE QUESTIONNAIRES (FORM 1)

As part of processing your request for an evaluation of your child's addition to our normative database, we must ask you to complete the form below about your child and your family. We greatly appreciate your willingness to complete this form. Your answers will give us a much better understanding of your child's behavior at home and in society. In completing this form, please follow these instructions as closely as possible:
1 . This form should be completed by the parent who has the primary responsibility for caring for this child. Where both parents reside with the child, this is to be the parent who spends the greatest amount of time with the child.
2. If a second parent wishes to complete a second informative form about this child, he/she may do so independently by requesting a second link to the form. He/she may call our administrative assistant and the form will be sent out promptly.
3. If your child is already taking medication for assistance with his/her behavior management, or for any emotional difficulties, we must ask that you remove your child from consideration by not completing this form and information the administration that your child is using medication.

Please respond carefully to this short questionnaire in order for us to properly organize.

    INFORMATION FOR THE STUDY

    General Identifier, allowing for process control.
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    CHILD AND FAMILY INFORMATION

    General information for our files. Beyond gender and date of birth, this information will not be used for the database, but it is required that we have on file for proof of validity.
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    EDUCATION

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    Developmental and Medical History

    Please respond to all relevant questions below to which you know the answer. If you do not know the answer, please skip forward to the next question.
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    Infant Health and Temperament

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    Early Develpmental Milestones

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    Health History

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