Family History
45. Has anyone in your family (children, parents, siblings, etc.) had problems with learning?
Yes 
No
No
If yes, please explain: ____________________________________________________________
______________________________________________________________________________
46. What was the highest grade achieved by your parents? Father:________ Mother:________
47. Does anyone in your family have difficulties with an attention-deficit disorder, substance
abuse, and/or mental health problem?
Yes
No
No
If yes, please explain: ____________________________________________________________
Health And Medical History
48. Do you have any recurrent or chronic health problems or conditions?
Yes
No
No
If yes, please specify: ____________________________________________________________
49. Have you ever had a serious accident or illness?
Yes
No
No
If yes, please specify: ____________________________________________________________
50. Have you ever been unconscious?
Yes
No
No
If yes, provide details: ____________________________________________________________
______________________________________________________________________________
51. Do you take any medications on a regular basis?
Yes
No
No
If yes, please list type of medication and purpose _______________________________________
______________________________________________________________________________
