CHILD/ADOLESCENT INTAKE INFORMATION

Transcription

1 CHILD/ADOLESCENT INTAKE INFORMATION Personal Data Today s Date: Client s Name: DOB: Age: Sex: M or F (circle one) Home Address: (street address, city, state, zip code) Home Phone: Work Phone Cell Phone Parent/Guardian s address: Parent s/guardian s Employer: Parent s/guardian s Occupation: Referred by: Emergency Contact Person: (name, relationship to client, phone #) Reason for Visit (Circle all that apply) Marital Depression Sexual Problems Family Conflict Anxiety School/Education Stress Behavioral Problems Alcohol/Drugs Legal/Custody Weight/Eating Grief/Loss Other reasons (please be specific): Insurance Information Insurance Carrier Policy # Policy Holder s Name DOB Age

2 Employer Group Number DEVELOPMENTAL HISTORY PRENATAL DEVELOPMENT Was this child was conceived through in vitro fertilization? Did mother receive medicines to increase fertility? Number of ultrasounds during pregnancy: Please describe any abnormal findings: Was the child a multiple birth? Was the child born first, second, etc? COMPLICATIONS WITH PREGNANCY (Please check off any of the following complications experienced by the mother while pregnant with this child) Anemia High Blood Pressure Toxemia Bleeding German Measles Injury RH incompatibility Chronic Illness Surgery Threatened Miscarriage Other Please describe any of the complications endorsed above: Please list and describe other complications/illnesses mother experienced during pregnancy: Please list any medications prescribed to mother during pregnancy: MOTHER S HEALTH HABITS WHILE PREGNANT (Please answer the following questions) Did the mother smoke cigarettes while pregnant? If yes, how often? Did the mother drink alcohol while pregnant? If yes, how often? Did the mother use any type of drugs while pregnant? If yes, what type and how often? BIRTH HISTORY (Please answer the following questions) How long was labor (i.e., how many hours from first contractions to birth)?

3 Was your baby born premature? If yes, how many days? After birth did your child stay in: Well-baby Nursery Neonatal Intensive Care Unit (NICU) DELIVERY/POST DELIVERY (Please check off any of the following items that pertain to the delivery and post delivery of this child) Natural childbirth Induced Breeched Cesarean Use of Anesthesia Use of Forceps Cord around neck Abnormal color Baby did not cry right away Difficulty breathing Received oxygen Received transfusions Received phototherapy Needed a respirator Please describe any additional complications: Please describe any medical problems your child had while in the nursery: Did mother and infant leave the hospital together? If not, please provide the reason: EARLY INFANT DEVELOPMENT (Please check off any of the following items that describe the child in the infancy) Poor weight gain Active baby Limp Stiff Tremors Convulsions Difficulty sucking Difficulty chewing Was the baby colicky? If yes, how long? Was the baby breast fed? If yes, how long? Was the baby bottle fed? If yes, for how long? Was/Is your child on special diet? Please describe diet: Please describe any other feeding issues? (sensitivities, textures, reflux, resistance, difficulty swallowing, drooling, etc.) DEVELOPMENTAL MILESTONES (Please note the age the following were achieved. If unsure of the age, check whether it was achieved early, late or within normal limits) Age Early Normal Late Age Early Normal Late Rolled over

4 Sat without support Crawled Stood up Walked holding on Walked without holding on Grasped pencil/crayon Babbled Spoke first words Put two words together Spoke in short sentences Repeats words and phrases Follow one-step directions Feeds self Developmental regression observed YES NO If YES answer the following: (circle)? a. Age regression observed (list): b. Describe the regression (list): MEDICAL HISTORY (Please check off whether your child experienced any of the following conditions. Please describe any of the conditions endorsed above, including age of onset/occurrence in the space provided.) Adenoidectomy Tonsillectomy Braces or other orthodontic appliances Ear infections Ear tubes (If yes, when) Meningitis Encephalitis Diabetes Asthma Allergies Seizures Head injury which required medical attention Loss of consciousness Heart defects Please describe any hospitalizations or injuries your child may have had Please report any medical diagnoses or conditions Please list all previous medications that were taken for more than one month: Name Dose Reason Given

5 Current Medications Vision Visual defects Glasses: Yes or No If yes, for what reason: Date of last vision screen: Results: Hearing Hearing Problems: Please circle Yes or No If yes, for what reason: Date of last hearing screen: Results: Please explain if you consulted with any other medical specialists for your child? Does your child have a diagnosis from a pediatrician, psychologist, psychiatrist, or other professional? If yes, please describe. Has your child ever had any of the following evaluations performed in school or privately? (Please provide copies of all prior test reports) Name of Evaluator Date of Evaluation Findings Physical Therapy Occupational Therapy Speech & Language Audiology Psychology Neurology Other: Has your child ever received any of the following therapies in school or privately? Explain. Physical Therapy Occupational Therapy Speech & Language Social Worker Psychologist Other: FAMILY HISTORY Siblings with autism (circle)? YES NO If YES answer the following: a. Is sibling an identical twin? YES NO

6 Siblings with autism-like behavior (circle)? YES NO If YES answer the following: a. Is sibling an identical twin? YES NO Family members with autism (circle)? YES NO If YES answer the following: a. Relationship to child (list): Family members with autism-like behavior YES NO If YES answer the following: (circle)? a. Relationship to child (list): Other health/developmental problems Epilepsy Mental retardation among family members (circle)? Other (list): Family history of genetic disorders Tuberous sclerosis Fragile X syndrome Schizophrenia Anxiety Bipolar disorder Depression Other (list): BEHAVIORAL HISTORY Unusual sensory sensitivities (circle)? YES NO If YES answer the following: a. Over sensitive to stimuli (list): b. Unusually interested in stimuli: (list): Abnormal eating or sleeping habits (list): Unusual fearfulness of harmless object (list) Lack of fear for real dangers (list): Self-injurious behaviors (list):

7 Socialization questions: Does the child a. cuddle like other children? b. look at you when you are talking or playing? c. smile in response to a smile from others? d. engage in reciprocal, back-and-forth play? e. play simple imitation games, such as pat-a-cake or peek-a boo? f. show interest in other children? Communication questions: Does the child a. point with his or her finger? b. gesture (e.g., non yes and no)? c. direct your attention by holding up objects for you to see? d. show things to people? e. give inconsistent response to his or her name (or to commands)? f. use rote, repetitive, or echolalic speech? g. memorize strings of words or scripts? Stereotyped behavior questions: Does the child a. have repetitive, stereotyped, or odd motor behavior? b. have preoccupations or a narrow range of interests? c. attend more to parts of an object (e.g., the wheels of a toy car)? d. have limited or absent pretend play? e. Imitate other people s actions? f. play with toys in the same exact way every time? g. appear strongly attached to a specific unusual object(s)?