Psychiatry CHILD, ADOLESCENT, AND FAMILY DATA MR #: Name: To be completed by parent or legal guardian.
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1 To be completed by parent or legal guardian. CHILD/TEEN S NAME DATE COMPLETED ETHNICITY BIRTH DATE AGE PERSON COMPLETING FORM LEGAL GUARDIAN? RELATIONSHIP Yes No MOTHER S NAME BEST PHONE NUMBER TO REACH YOU FATHER S NAME BEST PHONE NUMBER TO REACH YOU GUARDIAN S NAME (IF NOT MOTHER / FATHER) DAYTIME PHONE CHECK ONE: IF DIVORCED, WHO HAS LEGAL CUSTODY? YEAR DIVORCE OR SEPARATION FINALIZED Married Divorced Separated Unmarried SCHOOL NAME SCHOOL GRADE FAMILY S MAIN PROBLEM/MAJOR REASONS FOR SEEKING HELP NOW: DESCRIBE ANY OTHER BEHAVIORAL OR EMOTIONAL PROBLEMS: DESCRIBE THE IMPACT OF YOUR CHILD S PROBLEMS ON THE FAMILY: DESCRIBE YOUR CHILD S STRENGTHS AND UNIQUE QUALITIES: PAGE 1 OF 6
2 DESCRIBE WHAT HAS BEEN SUCCESSFUL IN DEALING WITH YOUR CHILD OR FAMILY S MAIN PROBLEM: INDIVIDUALS WHO CURRENTLY LIVE WITH THE CHILD (PLEASE SPECIFY IF MORE THAN ONE HOME): NAME AGE RELATIONSHIP OCCUPATION / SCHOOL GRADE Please check the box or boxes that most closely describe your child. Please provide additional clarification as indicated. DEVELOPMENTAL AND MEDICAL HISTORY PREGNANCY, LABOR, DELIVERY PROBLEMS: None Yes, please specify: CHILD EXPOSURE DURING PREGNANCY None Alcohol Drugs Tobacco Accident Illness DELAYS IN DEVELOPMENTAL MILESTONES None Talking Walking Toilet training Specify: BABY/INFANT BEHAVIOR DIFFICULTIES Ate well Easy to soothe Wanted to be left alone NO (Skip to next section) YES Colicky Easy to regulate (sleep, eat) Dare-devil behavior Clumsy Adaptable to transitions Head banging Other: MEDICAL PROBLEMS Allergies Operations Convulsions Asthma Poisoning Bladder / bowel problems Head injury Serious infection Ear infections Other: CURRENT MEDICATIONS: PAGE 2 OF 6
3 PSYCHOSOCIAL HISTORY SOCIAL SKILLS WITH PEERS Poor Average Good Unknown BEHAVIOR WITH SIBLINGS Poor Average Good N/A BEHAVIOR WITH PARENTS / GUARDIANS Poor Average Good Unknown DISCIPLINE STRATEGIES Verbal reprimands /discussions Remove privileges Helpful most of the time Physical punishment Time out Not helpful most of the time Grounding Reward / incentives EXERCISE PER WEEK (average hours) or more MEDIA USE PER DAY (average hours) or more (e.g., video games, computer, television) SLEEP PER NIGHT (average hours) less than CHILD ABUSE None Physical Sexual Emotional Neglect PENDING LEGAL ACTION No Yes: JUVENILE JUSTICE INVOLVEMENT No Yes: EDUCATIONAL HISTORY ACADEMIC PERFORMANCE Poor Average Good Unknown ACADEMIC SERVICES Home study Independent study SCHOOL PROBLEMS Learning problems Works hard, but does not do well Continuation school Repeated grade (grade: ) Gifted program Frequent discipline referrals or detention Speech therapy Suspensions / expulsions (#: ) Resource classes / special education Other school problems: Individualized Education Plan (IEP) PAGE 3 OF 6
4 Please check who of the child s biological family members had these conditions in the past or present. Please specify other biological relatives (aunt, uncle, grandparent) in the OTHERS column. MOTHER FATHER SIBLING OTHERS (SPECIFY) Childhood aggression, defi ance Childhood inattention, over-activity, and poor impulse control Learning disabilities Did not graduate high school Developmental delays Schizophrenia or psychosis Depression (2+ weeks), mood swings, or bipolar disorder Anxiety or obsessive/compulsive behaviors Tics / Tourette s Alcohol or drug abuse Antisocial (assaults to family and others, thefts, criminal, arrests) Physical, sexual, emotional abuse Please mark Yes or No to indicate if the following areas are currently problematic for your child/teen. If you indicate Yes, please provide a brief description of the problem. Self-injury, suicidal thoughts, homicidal thoughts: No Yes Alcohol or drug use: No Yes Exposure to traumatic event: No Yes Hearing or seeing things that others do not: No Yes Access to weapons: No Yes PAGE 4 OF 6
5 Please mark Yes or No to indicate if the following areas are currently problematic for your child/teen. If you indicate Yes, please mark which symptoms in the problem area frequently occur. INATTENTION, HYPERACTIVITY, OR IMPULSIVITY: No (skip to next section) Yes (complete items below) Makes careless mistakes or does not pay attention to details Fidgets with hands or feet or squirms in seat Problems sustaining attention Leaves classroom or other seat inappropriately Does not listen when spoken to directly Excessively runs about, climbs, or is restless Does not follow through on instructions or complete work Diffi culty playing quietly Problems organizing tasks and activities Always on the go Avoids, dislikes, or is reluctant to engage in tasks that Talks excessively require sustained mental effort (e.g., schoolwork) Blurts out answers to questions Loses things easily Diffi culty awaiting turn Forgetful Interrupts or intrudes on others OPPOSITIONAL OR DEFIANT BEHAVIOR: No (skip to next section) Yes (complete items below) Blames others for own mistakes Argues with adults Angry or resentful Deliberately annoys people Touchy or easily annoyed by others Loses temper Defi es authority fi gures requests or rules Desire to hurt others or get revenge FEELING SAD, DEPRESSED, OR IRRITABLE: No (skip to next section) Yes (complete items below) Depressed or irritable mood much of the time Fatigue or loss of energy Decreased interest or pleasure in activities Feeling worthless or excessively guilty Increased / decreased appetite Problems thinking, concentrating, or being indecisive Problems sleeping Recurrent thoughts of death or suicide Increased / decreased physical activity Self-harm or self-injurious behaviors (e.g., cutting) EXCESSIVE WORRY, FEAR, OR AVOIDANCE: No (skip to next section) Yes (complete items below) Excessive anxiety or worry (about past behaviors, Avoids or refuses to go to school future events, competence) Persistent worry about harm to family members Phobia or extreme fear Excessive distress when separated from family Excessive fear of social situations or public speaking Persistent refusal to sleep alone Avoids social situations or public speaking Repeated nightmares about separation from family Repetitive thoughts or impulses Repetitive behaviors PANIC (PERIOD OF EXTREME FEAR/DISCOMFORT): No (skip to next section) Yes (complete items below) Unrealistic concern about past behavior Nausea / abdominal distress Palpitations, pounding heart, accelerating heart rate Feeling dizzy, unsteady, lightheaded, faint Sweating Feelings of unreality or being detached from oneself Trembling or shaking Fear of losing control or going crazy Sensations of shortness of breath Fear of dying Feeling of choking Numbness or tingling sensations Chest pain / discomfort Chills or hot fl ashes PAGE 5 OF 6
6 Please mark Yes or No to indicate if the following areas are currently problematic for your child/teen. If you indicate Yes, please mark which symptoms in the problem area frequently occur. MOOD OR AGGRESSIVE BEHAVIOR PROBLEMS: No (skip to next section) Yes (complete items below) Excessive mood swings Racing thoughts Aggressive behavior Violent nightmares Explosive temper CONDUCT PROBLEMS: No (skip to next section) Yes (complete items below) Bullies, threatens, intimidates others Deliberate fi re setting Initiates physical fi ghts Deliberately destroyed others property Used an object as a weapon Broken into someone s house, building, car Physically cruel to people Lies to obtain goods / favors or avoid obligations Physically cruel to animals Stays out at night without parent permission Steals from person directly Ran away overnight twice Forced someone into sexual activity Truant from school EATING OR WEIGHT PROBLEMS: No (skip to next section) Yes (complete items below) Fear of gaining weight or being fat Self-induced vomiting, laxative use, or enema use Excessively restricts food intake Excessive exercise Binges on food Inaccurate perception of one s body SOCIAL AND DEVELOPMENTAL PROBLEMS: No (skip to next section) Yes (complete items below) Repetitive motor movements Abnormal social behavior Overreacts to changes in routine Teacher reports social problems Abnormal speech Extremely restricted interest or activities Poor eye contact Lack of interest in other children Reacts excessively to noise or touch CHILD S PREVIOUS TREATMENT: None Individual therapy Family therapy Inpatient Residential (overnight) Psychiatry (medication) IF ANY, PLEASE SPECIFY THE TREATMENT FOCUS AND PROVIDER(S): PAGE 6 OF 6
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Robert M. Cain, MD, PA 5508 Parkcrest Drive, Suite 310 Austin, Texas
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INITIAL INFORMATION PACKET
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ADD / ADHD Verification Form To be completed by Psychiatrist/Psychologist/or Diagnosing Physician
University of Nevada, Las Vegas Disability Resource Center 4505 S. Maryland Parkway Box 452015 Las Vegas, NV 89154-2015 Phone 702-895-0866 FAX 702-895-0651 www.unlv.edu/studentlife/drc ADD / ADHD Verification
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