Childhood Neurobehavioral Checklist The Melillo Childhood Neurobehavioral Hemisphere Checklist Consent* Yes No I consent that I am freely providing this information about my child for the purposes of diagnosis and/or treatment by Dr. Jeri LaVigne and that all information that is being collected will not be shared with anyone other than Dr. LaVigne and her staff.Your Name* First Last Email address* Child's Name* First Last Child's age*CHECK [ ] ALL SYMPTOMS OR CHARACTERISTICS THAT APPLY; THEN, ADD THE TOTAL NUMBER OF CHECKS BELOW EACH SECTION.MOTOR CHARACTERISTICS OF A RIGHT-BRAIN DELAY* Clumsiness and an odd posture Poor coordination Not athletically inclined and has no interest in popular childhood participation sports Low muscle tone – muscles seem kind of floppy Poor gross motor skills, such as difficulty learning to ride a bike and/or runs and/or walks oddly Repetitive/stereotyped motor mannerisms (spins in circles, flaps) Fidgets excessively Poor eye contact Walks or walked on toes TOTAL NUMBER OF CHECKS*MOTOR CHARACTERISTICS OF A LEFT-BRAIN DELAY* Fine motor problems (poor or slow handwriting) Difficulty with fine motor skills (dyspraxia), such as buttoning a shirt Poor or immature hand grip when writing Tends to write very large Stumbles over words when fatigued Exhibited delay in crawling, standing, and/or walking Loves sports and is good at them Good muscle tone Poor drawing skills Difficulty learning to play music Likes to fix things with the hands and is interested in anything mechanical Difficulty planning and coordinating body movements TOTAL NUMBER OF CHECKS*Section BreakTOTAL RIGHT BRAIN CHECKS*TOTAL LEFT BRAIN CHECKS:*Section BreakSENSORY CHARACTERISTICS OF A RIGHT-BRAIN DELAY* Poor spatial orientation – bumps into things often Sensitive to sound Confusion pointing to different body parts when asked Poor sense of balance High threshold for pain – doesn’t cry when gets cut Likes to spin, go on rides, swing, etc. – anything with motion Touch things compulsively A girl uninterested in makeup or jewelry Does not like the feel of clothing on arms or legs; pulls off of clothes Doesn’t like being touched and doesn’t like to touch things Incessantly smells everything Prefers bland food Does not notice strong smells, such as burning wood, popcorn, cookies Avoids food because of the way it looks Hates having to eat and is not even interested in sweets Extremely picky eater TOTAL NUMBER OF CHECKS*SENSORY CHARACTERISTICS OF A LEFT-BRAIN DELAY* Doesn’t seem to have many sensory “issues” or problems Good spatial awareness Good sense of balance Eats just about anything Has a normal to above average sense of taste and smell Likes to be touched Not sensitive to clothing Poor auditory or central processing Seems not to hear well, although hearing tests normal Delay in speaking was attributed to ear infections Gets motion sick and has other motion sickness issues Not under-sensitive or oversensitive TOTAL NUMBER OF CHECKS*Section BreakTOTAL RIGHT BRAIN CHECKS:*TOTAL LEFT BRAIN CHECKS:*Section BreakEMOTIONAL SYMPTOMS OF A RIGHT-BRAIN DEFICIENCY* Child spontaneously cries and/or laughs and has sudden outbursts of anger or fear. Worries a lot and tends to have phobias of many things Holds onto past “hurts” May have sudden emotional outburst that appear over-reactive, and inappropriate Experiences panic and/or anxiety attacks Sometimes displays dark or violent thoughts Face lacks expression; doesn’t exhibit much body language Lacks empathy Lacks emotional reciprocity Fearless, a dangerous risk taker Total Number of ChecksEMOTIONAL SYMPTOMS OF A LEFT-BRAIN DEFICIENCY* Overly happy and affectionate; loves to hug and kiss Frequently moody and irritable, depressed Loves doing new or different things but gets bored easily Lacks motivation Withdrawn and shy Excessively cautious or pessimistic and is extremely negative Doesn’t seem to get any pleasure out of life Socially withdrawn Cries easily; feelings get hurt easily Seems to be in touch with own feelings Empathetic to other people’s feelings; reads people’s emotions well Gets embarrassed easily Very sensitive to what others think about them TOTAL NUMBER OF CHECKS*Section BreakTOTAL RIGHT BRAIN CHECKS:*TOTAL LEFT BRAIN CHECKS:*Section BreakBEHAVIORAL CHARACTERISTICS OF A RIGHT-BRAIN DELAY* Thinks analytically all the time Often miss the gist of the story Always the last to get the joke Gets stuck in set behavior; can’t let it go Lacks social tact and/or is antisocial and/or socially isolated Poor time management; is always late Disorganized Problem paying attention Is hyperactive and/or impulsive Has obsessive thoughts or behavior Argues all the time and is generally uncooperative Exhibits signs of an eating disorder Failed to thrive as an infant Echolalia (mimicking sounds or words, repeatedly without really understanding the meaning) Appears bored, aloofness, and abrupt Considered strange by other children Inability to form friendships Inability to share enjoyment, interests, or achievements with other people Acts inappropriately giddy or silly Child has inappropriate social interactions (one-sided social interaction does not listen or care what another person is saying). Talks incessantly and asks repetitive questions No or little joint attention (pointing to object to get your attention) Didn’t look at self in the mirror as a toddler TOTAL NUMBER OF CHECKS*Section BreakTOTAL RIGHT BRAIN CHECKS:*TOTAL LEFT BRAIN CHECKS:*Section BreakBEHAVIORAL CHARACTERISTICS OF A LEFT-BRAIN DELAY* Procrastinates Extremely shy, especially around strangers Very good at nonverbal communications Is well liked by other children and teachers Does not have any behavioral problems in school Understands social rules Poor self-esteem Hates doing homework Very good at social interaction Makes good eye contact Likes to be around people and enjoys going to parties Doesn’t like to go to sleep-overs Not good at following routines Can’t follow multiple-step directions Seems to be very in touch with their own feelings Jumps to conclusions TOTAL NUMBER OF CHECKS*Section BreakTOTAL RIGHT BRAIN CHECKS:*TOTAL LEFT BRAIN CHECKS:*ACADEMIC CHARACTERISTICS OF A RIGHT-BRAIN DELAY* Poor math reasoning (word problems) Poor reading comprehension and pragmatic skills Issues with the big picture Very analytical Problem understanding jokes Very good at finding mistakes (spelling) Very literal Doesn’t always reach conclusions when speaking Early speech Precociousness (talked well early), even if slightly delayed IQ could be very high, but IQ’s run the whole spectrum; IQ’s often fall in the above-normal range in verbal ability and in the below-average range in performance abilities Was an early word reader Interested in unusual topics Learns in rote (memorizing) manner Learns in extraordinary-amounts of specific facts about a subject Impatient Speaks in monotones; little voice inflection Poor nonverbal communicator Doesn’t like loud noises and complains that volume is too low Speaks out loud regarding what he or she is thinking Talks “in your face” – is space invader Good reader but does not enjoy reading Analytically; lead by logic Follows rules without questioning them Good at keeping track of time Easily memorizes spelling and mathematical formulas Enjoys observing rather than participating Would rather read an instruction manual before trying something new Math is often the first academic subject to be viewed as problematic TOTAL NUMBER OF CHECKS*Section BreakTOTAL RIGHT BRAIN CHECKS:*TOTAL LEFT BRAIN CHECKS:*Section BreakACADEMIC CHARACTERISTICS OF A LEFT-BRAIN DELAY* Very good at big picture skills Good at abstract “thought free” association Poor analytical skills Very visual; loves images and patterns Constantly questions why you’re doing something or why rules exist No sense of time Child enjoys touching and feeling actual objects Has trouble prioritizing Unlikely to read instruction manual before trying something new Is naturally creative but, needs to apply themselves to develop their potential Would rather do things instead of observing Uses good voice inflection when speaking Misreads or omits common small words Child stumbles through loner words Reading too slow and laboriously Has difficulty naming colors, objects and letters as a toddler Needs to hear or see concepts many times in order to learn them Has shown a downward trend in achievement test scores or school performance Schoolwork is inconsistent Started as a late talker Has difficulty pronouncing words (poor with phonics) Had difficulty learning the alphabet, nursery rhymes or songs when young Has difficulty finishing work or finishing a conversation Acts before thinking and makes careless mistakes Tends to misread, omit or repeat words; child reads slowly Daydreams a lot Difficulty sequencing events in the proper order Letters are sometimes written backward Poor at basic math operations Poor memorization skills Child has poor academic ability Child has a lower verbal higher nonverbal IQ test results Performs poorly on verbal tests Needs to be told things several times before they understand Started to stutter as a child Doesn’t read directions well and is a poor test taker (misinterprets questions) TOTAL NUMBER OF CHECKS*COMMON IMMUNE CHARACTERISTICS OF A RIGHT BRAIN DELAY* Tends to have an over active immune response (has allergies) Rarely gets cold and infections Has had or has eczema or asthma Skin has little white bumps, especially on the back of the arms Erratic behavior – good one day, bad the next Craves certain food, especially dairy and wheat products TOTAL NUMBER OF CHECKS*Section BreakTOTAL RIGHT BRAIN CHECKS:*TOTAL LEFT BRAIN CHECKS:*COMMON IMMUNE CHARACTERISTICS OF A LEFT BRAIN DELAY* Gets chronic ear infections Prone to tumors; usually benign or cysts Has been on antibiotics a lot Has had tubes put in the ears (or seriously considered) Catches cold frequently No allergies TOTAL NUMBER OF CHECKS*COMMON AUTONOMIC CHARACTERISTICS OF A RIGHT BRAIN DELAY* Problems with bowel function; constipation, diarrhea Rapid heart rate and/or high blood pressure for age Appears bloated, especially after meals, and often complains of stomach pains Has body odor Sweats a lot Hands are always moist and clammy TOTAL NUMBER OF CHECKS*COMMON AUTONOMIC CHARACTERISTICS OF A LEFT BRAIN DELAY* Still wets the bed Has or had an irregular heartbeat (arrhythmia or heart murmur) TOTAL NUMBER OF CHECKS*Section BreakTOTAL RIGHT BRAIN CHECKS:*TOTAL LEFT BRAIN CHECKS:*Section BreakNow ADD UP each section for RIGHT checks and LEFT checks.TOTAL NUMBER OF CHECKMARKS RIGHT BRAIN :TOTAL NUMBER OF CHECKMARKS LEFT BRAIN :*HEMISPHERIC WEAKNESS RIGHT OR LEFT :*CAPTCHA Δ Contact Contact Dr. Jeri 678-886-5996 Dr. Jeri LaVigne Address 6284 Hunting Creek Rd NEAtlanta, GA 30328 Privacy Policy
