Medical History Form Adolescent
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1 Medical History Form Adolescent Today s date: IDENTIFYING INFORMATION: Child s name: Date of birth: Age: Yrs. Mos. Sex: M F School: Grade: Parent names: Stepparents involved: Child lives with: Other family members (list ages and in/out of home): Biological siblings: Step siblings: Others: Primary language spoken in home: REASON FOR REFERRAL: Referred by: Reason for visit: When was the reason first noticed? By whom? Previous diagnosis (list type and dates): Previous evaluations (list type and dates): Current/previous medications: Current/previous hospitalizations: Current/previous treatment (list type and dates): What are your concerns about your child? What do you hope will be gained by having your child seen at this clinic? medical history adolescent 1
2 MEDICAL CONTACTS: Pediatrician: Other physicians or therapists: Name: Name: PREGNANCY/BIRTH HISTORY: Please describe any significant pregnancy or birthing experiences: CHILDHOOD MEDICAL HISTORY: Check any of the following that apply. List age and explanation: Item Age Explanation Convulsions/seizures Meningitis Encephalitis Injury to head Fainting spells Measles Chronic illnesses Constipation Reflux Allergies Chronic cough Asthma Heart disorders Stomach or intestinal disorders Reactions to immunizations (specify) Chronic ear infections Hearing exam/poor hearing Vision exam/poor eyesight Sleep disorders Eating disorders Other FAMILY HISTORY: Check any of the following that apply. List relationship (i.e. mother, brother), and explanation: Family history of Relationship Explanation Learning disorders Emotional disorders Genetic disorders Attention disorders Speech/language disorders Substance abuse Other medical history adolescent 2
3 MOTOR DEVELOPMENT: Please describe any significant motor development delays or any treatment/therapy received: SPEECH AND LANGUAGE DEVELOPMENT: Please describe any significant speech, language, eating delays or behaviors as well as any treatment/therapy received: ACADEMIC/EDUCATION DEVELOPMENT: School: Phone: Address: Grade: Teacher: Most liked subjects: Least liked subjects: Future goals/plans: History: Schools attended Years Check any of the following that apply: Academic behaviors Poor physical coordination Poor handwriting, letter formation Poor memory, short-term and long-term Right-left confusion, directionality problems Hand dominance established late ( age) or not at all Late letter recognition Poor word recognition skills Poor reading comprehension Poor phonetic base Difficulty getting ideas on paper Problems in math Word problems and calculations Poor spelling in day-to-day assignments Problems with classwork or homework completion Procrastinates Forgets assignments/materials medical history adolescent 3
4 SOCIAL/EMOTIONAL BEHAVIORAL DEVELOPMENT (continued): Academic behaviors Poor attention and concentration Trouble keeping materials organized Conflict with teacher Certified for special education (LD resource help, MR, Speech, etc.) Drop in group achievement tests Repeated grade please list which grade(s): Expulsion/suspension from school SOCIAL/EMOTIONAL BEHAVIORAL DEVELOPMENT: Who generally disciplines the child? What methods are used: Do parents agree on methods of discipline? Yes No If no, describe: Check any of the following that apply: Behaviors Explanation Difficulty sleeping / Nightmares Enuresis (wetting) / Encopresis (soiling) Difficult to Discipline Temper tantrums Sad / Cries easily Unusually active, fidgety / Bites nails Unusually inactive, apathetic Difficulty with brothers and/or sisters Difficulty in getting along with other children Lacks age appropriate social interests Avoids peer interactions or other unfamiliar social contacts Socially inappropriate Prefers to be alone Inattentive / Impulsive / Distractible Unrealistic worry and/or pessimistic attitude Anxiety / Separation anxiety Panic attacks Difficulty with transitions Resists changes in environment Blames others for own mistakes Expresses no remorse Lies / Steals Truant / Excessive absenteeism School refusal Disregards family or community rules Argumentative Destructive medical history adolescent 4
5 SOCIAL/EMOTIONAL BEHAVIORAL DEVELOPMENT (continued): Behaviors Explanation Has panic attacks Has low productivity at school, work, home Is chronically tired or irritable Has decreased interest in pleasurable activities Has thoughts of death or suicide Has hallucinations or delusions Is socially inappropriate Has odd/bizarre ideas Has poor personal hygiene Is overly dependent/helpless Additional comments: Please note any major changes in your child s family, school, social life in the last 6 9 months, which could be important. If there is any specific information which has not been requested on this form but which would help us in understanding your child s problems, please include here: Thank you for taking the time to complete this form. It will help us serve your family better. If you have other critical documentation related to your concerns, please bring copies of records to your first appointment. medical history adolescent 5
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