subject_line
Child/Adolescent History Form
Today's Date
*
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Name of person completing form
*
Your email address
*
Date of First Appointment
Name of the Provide patient will be seeing
*
Dr. Lea Lockwood
First Name
*
Last Name
*
Birth Date
*
Sex
Male
Female
Parent/guardian contact email address
*
Confirm email
*
Pediatrician/PCP
Family Information
Mother's Information
First Name
Last Name
Birth Date
Age
Marital Status
Single
Married
Divorced
Widowed
Education
Occupation
Father's Information
First Name
Last Name
Birth Date
Age
Marital Status
Single
Married
Divorced
Widowed
Education
Occupation
Does the child have any step-parents?
*
Yes
No
If so, please provide names and dates of relationships
If parents are divorced, do parents have joint legal custody?
Yes
No
What is the current visitation schedule for this child?
Others Living in Home (siblings, step-siblings, grandparents, etc.)
Name
Age
Education
Relationship to child
1.
Name
Age
Education
Relationship to child
2.
Name
Age
Education
Relationship to child
3.
Name
Age
Education
Relationship to child
4.
Name
Age
Education
Relationship to child
5.
Name
Age
Education
Relationship to child
Other Siblings Not Living in Home
Name
Age
Education
Relationship to Child
1.
Name
Age
Education
Relationship to Child
2.
Name
Age
Education
Relationship to Child
3.
Name
Age
Education
Relationship to Child
4.
Name
Age
Education
Relationship to Child
Please describe any geographical and/or school moves this child has made
Pregnancy and Birth History
Length of pregnancy
Duration of Labor
Birth Weight
Age of mother at delivery
Was the delivery
Vaginal
Routine Caesarean
Emergency Caesarean
Did the mother experience any complications during her pregnancy (e.g., gestational diabetes, preeclampsia, serious illnesses or injuries, extreme stress)?
Did the mother receive regular prenatal care during the pregnancy?
Yes
No
Did the mother/baby experience any complications during the child's birth (e.g., emergency c-section, infection, excessive bleeding, premature labor, etc)?
Did the child experience any complications during delivery or in the hours following birth (e.g., premature birth, difficulty breathing, seizures, fever, jaundice, maconium staining, significant heart rate deceleration, cord wrapped, etc.)? Please indicate your child's two apgar scores, if known, at the time of birth.
How old was this child at discharge from the hospital after birth?
Developmental History
Child's Handedness
*
Right
Left
Both
When did this child
Roll over?
Crawl?
Take first steps?
First
Roll over?
Crawl?
Take first steps?
Speak first words?
Speak in sentences?
Toilet train?
first
Speak first words?
Speak in sentences?
Toilet train?
Was this child ever referred for or did this child ever receive early intervention services, or has this child at any time received any speech and language therapy, occupational therapy, or physical therapy services?
Yes
No
If yes, please provide dates and providers
How would you describe this child's temperament in the first year of life?
Child's Medical and Psychiatric History
Are this child's immunizations up to date?
Yes
No
If no, please describe
Has this child been exposed to poisons or toxins (e.g., lead)?
Yes
No
If yes, please list what they were exposed to and when
Please describe any accidents, injuries, head injuries, loss of consciousness, concussions, major illness, surgeries, or hospitalizations this child has experienced.
Does this child suffer from any chronic illnesses (e.g., asthma, diabetes, epilepsy)?
*
Yes
No
If yes, please list illnesses
Does this child have any problems with
Vision
Hearing
Gross Motor
Fine Motor
Headaches
Stomachaches/Vomiting
Allergies
Falling Asleep
Staying Asleep
Early Rising
Bedtime Fears
Restlessness
Bladder/Bowel control
Tics
Nervous Habits
Repetitive Movements
Increased Appetite
Decreased Appetite
Cutting Self
Hitting Self
Burning Self
If any items are checked, please explain briefly including any other unusual thoughts or behaviors that are concerning to you.
Has this child had any previous psychological, psychoeducational, neuropsychological, or neurological evaluations?
Yes
No
If yes, please include dates of evaluations and names of providers. Please bring copies with you to your first appointment so they can be left in your child's medical record.
Has this child ever received therapy services before?
Yes
No
If yes, please provide dates and names of providers
Any challenges/concerns re:sleeping?
Yes
No
If yes, please explain:
If yes, when did this begin?
What time does your child go to bed?
Any challenges/concern re:eating?
Yes
No
If yes, please explain:
Does your child eat a balanced diet?
Yes
No
Please explain either answer
Does your pediatrician have any concerns about your child's growth?
Yes
No
If yes, please explain:
Family Psychiatric and Medical History
Below, please provide any information you have regarding any family history of psychiatric issues (i.e. depression, anxiety, bipolar disorder, substance abuse, schizophrenia, dementia, OCD, attention deficit disorder, suicide, etc)
Below, please list the major physical health issues of biological family members and their relationship to you
Educational History
Did the child attend:
Nursery/Preschool?
Yes
No
If so, where?
Kindergarten?
Yes
No
If so, where?
What school is the child currently attending?
What is the child's current grade?
Who is his/her teacher?
Has the child repeated any grades?
Has the child skipped any grades?
How does the child perform academically? (1=Above average, 2=Average, 3=Before Average, 4=Failing)
1
2
3
4
Math
1
2
3
4
Reading
1
2
3
4
Spelling
1
2
3
4
Writing
1
2
3
4
Science
1
2
3
4
Social Studies
1
2
3
4
Does this child have an IEP or 504 plan
Yes
No
If yes, please describe
Is this child in the gifted program?
Yes
No
Does this child miss school frequently?
Yes
No
If yes, please explain
Has this child ever been suspended or expelled from school?
Yes
No
Does this child exhibit behavioral, social, or attentional problems at school?
Yes
No
Social and Emotional History
In your opinion, what mood is this child in most of the time?
Does this child exhibit frequent mood changes?
Does this child have significant fears, or does this child worry a great deal?
Does this child demonstrate poor attention, hyperactivity, impulsive behavior, or temper tantrums?
How many friends does this child have?
How much time does this child play with friends per day?
How well does this child make and keep friends?
How old are most of this child's friends?
Same Age
Older
Younger
How does this child get along with peers?
How does this child get along with his/her siblings?
How does this child get along with adults (e.g., parents, teachers, coaches)?
Does this child exhibit any problems with defiance of adults requests?
What methods have you used to discipline this child? Have they been effective?
Do all of this child's caregivers agree on how to discipline this child and which behaviors to discipline?
Does this child engage in
Stealing
Lying
Fire Setting
Running Away
Truancy from School
Cruelty to People
Cruelty to Animals
Destruction of Property
Has this child ever been arrested or involved in a legal matter?
What are this child's favorite activities?
What are this child's best qualities?
Please describe the reason you are seeking services and provide as much detail as you would like
Please check the following concerns that your child/teen has demonstrated in the last 3-6 months.
Aggressive behavior
Alcohol abuse/overuse
Anger outbursts
Anxiety or excessive fear/worry
Attention/concentration problems
"Bad" friends
Bingeing
Decreased energy
Decreased sex drive
Depressed/down/unhappy mood
Dissociative states
Divorce adjustment
Euphoria
Fears/phobias
Flashbacks
Grief
Guilt (excessive)
Hallucinations
Having extra energy
Hopelessness/helplessness
Hyperactivity
Hypersexuality
Impulsivity
Insomnia
Irritability
Learning problems
Marijuana or other drug use
Memory problems
Mood fluctuating rapidly up and down
Obsessions/compulsions
On guard or edgy
Oppositional behavior
Panic attacks
Paranoid thoughts
Pressured/rapid speech
Purging behaviors
Restricting food intake
School avoidance
Social/peer problems
Sleep problems/little or too much
Somatic/physical complaints
Weight gain (significant)
Weight loss (significant)
Worthlessness