CHILD/ADOLESCENT HISTORY

Transcription

1 CHILD/ADOLESCENT HISTORY Child s Name Date Gender with whih hild identifies M F Child s Age Child s DOB Referred by Person Completing Form Relationship to Child Residene of Child Biologial/Step Parents Adoptive Parents Foster Parents Other Presenting Problems Please desribe why you are seeking servies for this hild: When did you first notie the problem? Has this problem affeted his/her funtioning? At home: Severe Substantial Moderate Mild Minimal At shool: Severe Substantial Moderate Mild Minimal Community: Severe Substantial Moderate Mild Minimal Is the hild experiening problems in any of the following areas? Aggressive behavior Anxiety/Worry Attention span Changes in eating habits Changes in sleeping habits/problems sleeping Cruelty to animals Destroying property Disobediene Distorted body image Fears Headahes/Stomahahes Hearing/Seeing strange things Hopelessness/Helplessness/Worthlessness Hyperativity Intrusive/Reurrent memories Irritability Lak of interest in things Language impairments Lying/Stealing Low self-esteem Nightmares Obsessive thoughts/compulsive Behaviors Delaware Ave., Delmar, NY Phone: (518) Fax: (518) Page 1 of 7

2 Paranoia Raing thoughts Restlessness Sadness/Crying Sexual behavior Soial relationships/anxiety Suiidal talk/self harm behaviors Tantrums Toileting (wetting/soiling) Withdrawal/Isolating behaviors Family Information Individuals living in the household: Name Age Relationship to Child Relationship with Child Parent s eduational bakground and oupation: Mother Father Has the hild experiened any of the following stressful events? (Please list hild s age at the time of event) Death of family member Divore or separation of parents Frequent moves Head Start Long term illness of family member Are there marital or parenting struggles? Yes No : Housing Issues: Safe/stable Unsafe/inadequate Temporary Foster are Conflit with neighbors/landlord None Other Soial History Has the hild ever been involved in any of the following servies? (Please list hild s age at the time of event) Child Protetive Servies Probation/Juvenile Probation/Detention Boys and Girls Club Youth Servies Head Start Early Intervention Servies (ages 0-3)/Developmental Preshool Is the hild the respondent s biologial hild? Yes No Delaware Ave., Delmar, NY Phone: (518) Fax: (518) Page 2 of 7

3 If no, what age did he/she ome into your are? At what age was the adoption? Is there any ontat with the biologial parents? Yes No If yes, please desribe: Where was the hild born and raised? Does the hild have quality relationships with peers? Yes No : Child s sexual history (if appliable): Soial/Environmental Issues: Soial isolation/withdrawal Negative peer influenes Lifestyle hange Family onflit Conflit with aregivers Lak of Servies Other, explain: The following information is optional. Please mark the appropriate line(s). I hoose to provide this information I hoose not to provide this information Do you have a religious or spiritual identity? Yes No Unknown If yes, what is that preferene? What is the rae of the hild? Euro-Western or White Amerian Indian or Alaska Native Hispani or Latino Native Hawaiian Blak or Afrian Amerian Asian Amerian or Asian Unknown Other Has the hild ever experiened problems related to rae, religion, or ulture? Yes No Unknown : Please desribe your hild s temperament and ativity level as an infant: Overly alm/inative Calm/reasonably ative Very ative/overly ative Other : When young, how did your hild interat with other hildren? Shy/inhibited Reasonably outgoing/enjoyed interating with others Overly outgoing/problemati Other : Does your hild have any urrent soial diffiulties? Yes No If yes, does your hild have trouble with Making new friends Keeping friendships Approahing other hildren Violating personal spae Disinterest in soial relationships Other : Mental Health History Has the hild or immediate family member ever been to ounseling or seen a psyhiatrist? Yes No Unknown Treatment Reeived Individual Date(s) Diagnosis (inpatient, outpatient, residential, et) Response Delaware Ave., Delmar, NY Phone: (518) Fax: (518) Page 3 of 7

4 Has the hild ever expressed suiidal thoughts or attempted suiide? Yes No Unknown : Has the hild or any other family member ever been abused or negleted? Yes No Unknown (Please explain): Does the hild use drugs or alohol (inluding tobao)? Yes No Unknown Please list type, amount, frequeny, and dates (first use, last use): Name Amount Frequeny Date(s) Family history of mental/medial illness: (Please speify who and when first diagnosed) ADHD Anxiety/Pani Attaks Alohol/Drug Abuse Autism/Asperger s/pervasive Developmental Disorder Bipolar Depression Learning Disability Mental Retardation/Intelletual Disability Nervous Breakdown Obsessive Compulsive Disorder (OCD) Pani Disorder Post-Traumati Stress Disorder (PTSD) Psyhiatri Hospitalizations Shizophrenia Suiide Caner (Type) Diabetes/High Blood-Pressure Heart or Lung Problems Immunologial Disorders (Lupus, Inflammatory Bowel Disease) Migraines Seizures Thyroid Other Developmental History Mother s age during pregnany: Length of pregnany: Any previous pregnanies (number)? Any previous misarriages (number)? Did mother reeive regular prenatal are? Yes No When did prenatal are begin? Were there any medial onerns about the pregnany? Yes No If yes, please desribe: Did mother use prenatal vitamins? Yes No How muh weight did mother gain? Did the mother experiene any of the following during pregnany? (Please indiate # of months into pregnany) Delaware Ave., Delmar, NY Phone: (518) Fax: (518) Page 4 of 7

5 Aidents or injuries Emotional stress Illness or infetion Bleeding Fevers Indued labor Rh/Blood inompatibilities High blood pressure/swelling Toxemia Diabetes Hospitalizations Diet Problems Other : Did the mother use any drugs, alohol, and/or mediations during pregnany (inluding niotine, presription and over the ounter drugs)? Yes No Unknown Type of delivery (-setional,vaginal): Were foreps used? Yes No What was the hild s birth weight? Length? Drug Abused or suspeted abuse: Alohol Tobao Marijuana Methamphetamine Coaine Presription Mediations Other Drugs If known, please list the frequeny and months taken (e.g. daily, weekly, oasionally; months 1-9): Were there any problems or ompliations with delivery? Fetal Distress Plaenta Abruption Prolapse Cord Cord Around Nek Jaundie Meonium Aspiration Unknown : Were there any problems with baby s health before or immediately after delivery? Yes No Unknown : Did the Child Spend any Time in the NICU after Birth Yes No Unknown If so, what was the length (in days) spent in the NICU? Were mother and baby separated after birth for more than 24 hours at a time? Yes No Unknown : Were there any onerns about the hild s early development/1 st year? No Conerns Unknown Failure to Grow Trouble Feeding Respiratory Distress/Trouble Breathing Cardia Issues Other (Please Explain): At what age did the hild aomplish the following tasks? Roll over Use first words Drawing irles Crawl Use 2-3 word sentenes Toilet trained Walk Build tower with ubes Dress themselves Waving bye bye/blowing kisses/pointing Were there any aomplishments that the hild mastered and then lost? Yes No Unknown : Does the Child have a history of sensory onerns; oversensitive to Loud Noises Touh Light Smell Other (Please Explain): Has the hild ever reeived any previous developmental therapy: Yes No Unknown Type of Therapy: Speeh/Language Physial Oupational Therapy Developmental Health History Primary Care Provider Other Providers Speialty Number of Years Date of Last Exam Delaware Ave., Delmar, NY Phone: (518) Fax: (518) Page 5 of 7

6 Is the hild urrently experiening any health problems? Yes No Unknown : Is the hild suffering from any allergies? Yes No Unknown (Please name and desribe reation) Please list the mediations the hild is urrently taking (medial and psyhiatri): Name of Mediation Dosage/Frequeny Date Started Please list all the psyhiatri mediations that have been tried in the past (if neessary, please attah separate list). Name Highest Dosage Duration Response Reason for Stopping Example: Dexedrine 5mg twie daily 09/98-11/98 Good Poor Sleep Has the hild ever been hospitalized for medial reasons? Yes No Unknown Does the hild suffer from any hroni medial problems? Yes No Unknown Has the hild had any serious illnesses, aidents, surgeries, or injuries? Yes No Unknown Has the hild experiened any of the following health problems in the past? Constipation/Diarrhea Head injury/loss of onsiousness Neurologial Diabetes Seizures Tis Ear/hearing problems Heart Kidney/Bladder Eye/vision Lung Weight (loss/gain) Frequent Infetions Thyroid Dysregulation Other : Delaware Ave., Delmar, NY Phone: (518) Fax: (518) Page 6 of 7

7 Has the hild ever had any medial issues warranting imaging tests (MRI, EEG, CT, EKG)? Yes No Unknown Reason For Testing: Results of Testing: Have there been problems with hormonal mood dysregulation? Yes No Unknown : Sleep Patterns: Total hours of sleep per night: Usual sleep shedule: to Does the hild take naps during the day? Yes No If yes, how many hours per day? Please indiate any sleep pattern onerns: Current Problem Change Within Last 6 Months Diffiulty falling asleep Yes No Yes No Frequent awakening Yes No Yes No Snoring Yes No Yes No Restlessness/Movements Yes No Yes No Early morning awakenings Yes No Yes No Nightmares Yes No Yes No Not rested Yes No Yes No If yes to any of the onerns, please desribe: What is the hild s urrent grade in shool Has the hild repeated or skipped grades? What are the hild s urrent aademi grades? What are the hild s aademi strengths? What are the hild s aademi hallenges? What are your hild s favorite ativities? Eduational History Have there been any hanges in the hild s performane at shool? Yes No Unknown : Has there been any psyhoeduational (inluding IQ) or neuropsyhologial testing ompleted on the hild at shool or elsewhere? Yes No Unknown (Please explain and provide releases) Does the hild urrently partiipate in speial eduation lasses or reeive other speial servies or formal aommodations (IEP or 504 plan)? Yes No Unknown Have any of the hild s immediate family members had problems in shool? Yes No Unknown : What is the hild s attitude toward shool? Positive Indifferent Negative Has the hild ever been: Truant Suspended Expelled Had exessive shool absenes Delaware Ave., Delmar, NY Phone: (518) Fax: (518) Page 7 of 7