Department of Psychiatry\Behavioral Health 200 Mercy Drive, Suite 201 Dubuque, IA or
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1 Department of Psychiatry\Behavioral Health 200 Mercy Drive, Suite 201 Dubuque, IA or C H I L D H I S T O R Y F O R M Today s Date: Child s Name: Date of Birth: Age: Grade: Person Completing Form: Relation to Child: Address: Phone Number(s): e mail: MEMBERS OF THE HOUSEHOLD List in order of birth all members of the household as well as any immediate family members living outside of the household. Name Birth Date Sex Employer/ School General Health/ Comments CHILD S DEVELOPMENT PRENATAL AND BIRTH INFORMATION Duration of Pregnancy: weeks Complications: Anemia High Blood Pressure Preeclampsia (Toxemia) Heart Disease Significant Bleeding German Measles Virus RH Incompatibility 1 File to: Psychiatry
2 Complications Continued: Injury/ Accident Hospitalization Operation Threatened miscarriage Medications/ Drugs Taken Alcohol Consumed Smoked Other Birth History: Name of Hospital: Medications Administered: Natural Birth or Cesarean: Length of Labor: Instruments Used: Birth Weight: Length: Apgar Scores: Was Labor Induced? Was baby s color normal? Did baby breathe spontaneously? Did baby receive oxygen? Did baby have jaundice? If Yes, what was the treatment? Length of Hospital Stay: Other Delivery/ Birth/ Postnatal Complications: Did mother experience postpartum depression ( Baby Blues )? CHILD S DEVELOPMENT INFANCY AND TODDLER INFORMATION How was the baby fed? Breastfed Bottle fed Both When was the baby weaned? Problems with feeding or weaning: Baby experienced colic: Difficulties sucking, swallowing or chewing: Difficulties with weight gain: Sleep difficulties: Concerns regarding responsiveness: Was the baby easy or difficult to soothe? 2
3 Developmental Milestones Age Achieved Comments Sit without support Crawl Walk unaided Pedal tricycle Ride bicycle Toilet Trained Day Toilet Trained Night Say single words Combined words or 2 word phrases MEDICAL HISTORY Illness/ Injury Meningitis/ Encephalitis Head Injury Frequent ear infections Hearing difficulties Vision difficulties Gastrointestinal problems Allergies Asthma Seizures Convulsions Cerebral Palsy High Fever (104 degrees+) Diabetes Oxygen deprivation (anoxia) High lead level Other Present Medications Past Medications FAMILY HISTORY Have any blood relatives been formally diagnosed or had symptoms of the following: Yes No If yes, whom (Relation to Child) ADD/ ADHD Autism/ Asperger s Syndrome Anxiety Disorder Bipolar / Manic Depression Depression Obsessive Compulsive Disorder Tourette s Disorder/ Tics 3
4 Yes No If yes, whom (Relation to Child) Cognitive Delays/ Challenges Learning Difficulties Nervous Breakdown Schizophrenia Eating Disorder Speech/ Language Problem Epilepsy/ Seizure Disorder Sleep Apnea/ Disorder Alzheimer s Disease Cancer Alcohol/ Drug Abuse Chronic Headache Migraine Stroke Heart Trouble High Blood Pressure PREVIOUS CONSULTATIONS/ EVALUATIONS Yes No Date Diagnosis/ Results Hearing Vision Neurologist Psychologist Psychiatrist Educational Speech/ Language Occupational Therapy Physical Therapy Other EDUCATIONAL HISTORY Current School Grade Teacher s Name(s) Concerns? Previous School Attended Dates Problems/ Teacher Concerns Was child ever evaluated by the school district (If yes, specify when): Does your child receive Special Education Services: Yes No Specify: 4
5 CURRENT CONCERNS Diet/ Nutrition Sleep Pattern Physical Complaints Academic Skills Intellectual Ability Fine Motor Skills Gross Motor Skills Language Skills Attention Impulsivity Overactivity Passivity Social Difficulties Shyness Withdrawal Anxiety Specific Fears Obsessions Sadness Irritability/ Anger Defiance Hurting Self Hurting Others Tantrums Apathy Family Relationships Trauma Self Stimulatory Behavior Toileting/ Soiling Sexual Issues Other Concerns List child s strengths and interests: Please explain why you have referred your child for this evaluation and/ or treatment:
CHILD/ADOLESCENT INTAKE INFORMATION
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