PACIFIC PSYCHIATRY, INC.

Transcription

1 PACIFIC PSYCHIATRY, INC. Douglas P. Murphy, M.D. Child & Adolescent and General Adult Psychiatry 175 Santa Rosa Street, San Luis Obispo, CA Phone: (805) ; FAX: (805) ADOLESCENT DEMOGRAPHIC, DEVELOPMENTAL & TREATMENT HISTORY QUESTIONNAIRE CHILD S NAME: DOB: AGE: SEX: Male Female CHILD S HEALTH CARE PROVIDERS Pediatrician Therapist Name Phone Name Phone Address FAX Address FAX City/State/Zip City/State/Zip CHILD S PARENTS Married Divorced Separated Never Married Father Step-mother or Significant Other Name Age Name Age Address DOB Address DOB City/State/Zip City/State/Zip Hm Phone Educ Level Hm Phone Educ Level Cell Phone Cell Phone Mother Step-father or Significant Other Name: Age: Name: Age: Address DOB Address DOB City/State/Zip City/State/Zip Hm Phone Educ Level Hm Phone Educ Level Cell Phone Cell Phone Child lives with (check one): Both parents Relatives who are not parents A single parent A foster family Mother and step-father Adoptive parent(s) Father and step-mother In a treatment facility If a treatment facility, specify type: SIBLINGS Chronological Order from Oldest to Youngest (if more siblings check box). Name Sex Age Half-Step Live with School PAC*-Adolesc-DemoDevTx *

2 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 2 CHILD CUSTODY - IF INDICATED. ( Indicated Not Indicated) If the parents are separated or divorced, who has custody of the child? If there is a custody determination made by a Court of Law, it is imperative that you bring a copy of the Court Order with you to your child s first appointment. Legal Custody Physical Custody Name Age Name Age Location Educ Level Location Educ Level City/State/Zip City/State/Zip Employment Employment Mental Health History Psychiatric History Mental Health History Psychiatric History Custody Order brought to first appointment? Yes. No ADOPTIVE HISTORY IF INDICATED ( Indicated Not Indicated) If this child is adopted, when: / and at what age: / month year yrs mos Circumstances that caused the child to become adopted (check all that apply). Neglect of Child Abuse of Child Physical or Otherwise Parent Unable to Provide for Child Reason: Other Problem Specify: This child is (check one): Oldest Middle Youngest Only Child CHILD S NATURAL PARENTS If Known. Birth Father Birth Mother Name Age Name Age Location - City/State Educ Level Location - City/State Educ Level Employment Employment Mental Health History Psychiatric History Mental Health History Psychiatric History Does anyone else live at home besides the child, parents, brothers and sisters? If yes, please list relationship, age and health: RELATIONSHIP AGE HEALTH

3 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 3 CURRENT PROBLEM 1. What are the reasons for the current evaluation (check all that apply): Mood Problem Anxiety Problem Behavioral Problem at School Behavioral Problem at Home Learning Problem Speech or Language Problem Social Skills Problem Other Problem Specify: 2. Please briefly describe the nature of the current problem: 3. How long have these problems been evident: 2 months or less 3 to 6 months 7 to 12 months More than 12 months 4. Has your child previously been evaluated for this problem? If so, when and by whom? 5*. Please list all medications your child is currently taking (*if necessary, continue on the reverse side): Medication Dose Reason Year Outcome 6. Is there an allergy to medications or other allergy? If yes, allergic to: Foods Drugs Dusts or pollens Other To which medications are you allergic? PSYCHIATRIC TREATMENT HISTORY 7*. Please list in chronological order (first to last), all behavioral health professionals (psychiatrist, psychologist, other mental health practitioner) with whom your child has previously received an evaluation or treatment, including the location, year and reason for treatment (*if necessary, continue on the reverse side): Clinician Location Year Reason It is important that you bring a copy of medical and psychological records with you to your first appointment.

4 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 4 8. Have any of the following diagnoses been related to your child s care in the past? Aphasic or Language Difficulty Neurological Disorder Seizure DO or Convulsions Post-traumatic Stress Autistic or Mentally Retarded Psychotic Disorder Brain Injury Seizure Disorder Depression or Anxiety Slow Learner or Learning Disabled Attention Deficit/Hyperactivity (ADHD) Tic or Tourette s Syndrome Please provide here any additional information from questions 5 & 7 on previous page current medications and list of behavioral health professionals including the location, year and reason for treatment. FAMILY PSYCHIATRIC HISTORY 1. Have any blood relatives experienced psychiatric problem(s)? 2. Have any blood relatives been treated for psychiatric problem(s)? 3. Have any blood relatives been treated in a psychiatric hospital? 4. Have any blood relatives experienced a substance abuse problem? 5. Have any blood relatives been treated for a substance abuse problem? If any yes answer to questions 1-5, please state which relative(s) and the problem/treatment: Psychiatric Problem Relative Treatment Received

5 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 5 MEDICATIONS CHECK LIST Please thoroughly review the following medications. Circle any medication your child currently or has ever taken for whatever reason, even if it was taken just once. Include drugs used recreationally. ANTIDEPRESSANT SSRI Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram), Lexapro (excatalipram) SNRI Effexor (venlafaxine), Cymbalta (duloxetine), Pristiq (desvenlafaxine) NDRI Wellbutrin (bupropion) Other Remeron (mirtazipine), Serzone (nefazidone), Viibryd (vilazodone), Desyrel (trazodone) TCAD - Elavil (amitriptyline), Tofranil (imipramine), Pamelor (nortriptyline), Norpramin (desipramine) Anafranil (clomipramine), Sinequan (doxepin), Vivactil (protriptyline) MAOI Nardil (phenelzine), Parnate (tranylcyromine), Marplan (isocarboxazid) ANTI-ANXIETY SLEEP Klonapin (clonazepam), Ativan (lorazepam), Xanax (alparzolam), Valium (diazepam) Buspar (buspirone) Benzodiazepine: Restoril (temazepam), Klonapin (clonazepam), Ativan (lorazepam), Chloral Hydrate* Non-Benzo: Ambien (zolpidem), Sonata (zaleplon), Lunesta (eszopiclone); Benadryl (diphenhydramine) Melatonin-Ag: Rozerem (ramelteon), Melatonin (diphenhydramine); Antidepressant: Desyrel (trazodone); Elavil (amitriptyline); Doxepin (Sinequan); Seroquel (diphenhydramine); STIMULANT/ADHD Methylphenidate: Ritalin, Concerta, Focalin, Vyvanse, Ritalin LA, Methylin, Metadate Dextroamphetamine: Adderall, Dexedrine, Dexedrine Spansules, Dextrostat Nonstimulants: Strattera (atomoxatine), Provigil (modafinil), Catapres (clonidine), Intuniv or Tenex (guanfacine) MOOD STABILIZER Lithium, Lithobid, Eskalith, Depakote (valproic acid), Tegretol (carbamazepine), Trileptal (oxcarbazine) Lamictal (limotragine), Topamax (topiramate), Neurontin (gabapentin) NEUROLEPTIC PAIN NOVEL - Risperdal (risperidone), Zyprexa (olanzepine), Seroquel (quetiapine), Geodon (ziparzidone), Abilify (aripiprazole), Invega (paliperidone), Fanapt (iloperidone), Clozaril (clozapine) TYPICAL Haldol (haloperidol), Prolixin (fluphenazine), Trilafon (perphenazine), Orap (pimozide), Navane (thiothixene), Stelazine (trifluoperazine), Loxitane (loxapine), Moban (molindone), Thorazine (chlorpromazine), Mellaril (thioridazine). Neurontin (gabapentin), Lyrica (pregabalin), Gabitril (tiagabine), Topamax (topiramate), Depakote (valproic acid) Darvocet, Fiornal, Norco, Percoset, Tylox, Vicodin, Codeine, Methadone, Morphine, MSContin, Oxycodone, Dilaudid SUBSTANCE ABUSE Alcohol Dependence - Antabuse (disulfiram), Campral (acamprosate), ReVia (naltrexone) Other Drug Dependence - Methadone, Suboxone (buprenorphine & naltrexone), Subutex (buprenorphine) Withdrawal - Tranxene (clorazepate), Librium (chlordiazepoxide), Catapres (clonidine),

6 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 6 PSYCHIATRIC REVIEW OF SYMPTOMS/PROBLEMS LIST Please review the following psychiatric symptoms. Please circle or check the box next to (to the left of) any symptom(s) you are currently experiencing or have ever in the past experienced to a degree that would be considered ABNORMAL. MOOD ANXIETY TRAUMA DEPRESSION Depressed Mood; Insomnia; Decreased Interest in Pleasurable Activity; Unreasonable Guilt or Worthlessness; Low Energy; Poor Concentration; Decreased Appetite; Extremely Low Physical Activity; Suicide Thoughts; Suicide Plan; Suicide Attempt MANIA Abnormally Elevated Mood; Abnormally Irritable Mood; Decreased Need for Sleep; Racing Thoughts; Rapid Pressured Speech; Distractibility; Extremely Physically Active; Risky Pleasure-seeking Behavior (out-of-control spending, sexual indiscretions, uncharacteristic fighting). PANIC A Distinct Period of Intense Fear; Heart Pounding; Dizziness Numbness & Tingling; Chest Pain; Shortness of Breath; Sweating; Shaking or Trembling; Nausea; Choking; Overwhelming Fear of Death; Fear of Losing Control or Going Crazy; Derealization/Depersonalization;. GENERALIZED Frequently Overanxious; Excessive Worry; Irritability; Muscle Tension; Feeling Keyed Up; Easily Fatigued; Difficulty Concentrating; Sleep Disturbance. PHOBIA Excessive Fear of a Specific Object or Situation; Fear of Leaving Home; Fear of Social Situations. OCD Repeated Fear or Distressing Thoughts or Images About: Germs or Contamination; Order/Symmetry; Something Terrible Happening; Checking Stove, Light Switches, etc. Harming Self or Others; Repetitive Behaviors or Mental Acts Such As: Checking Stove, Light Switches, etc.; Ordering & Arranging; TRAUMATIC STRESS History of Traumatic Event; Avoidance of Symbols associated with the Trauma; Washing, Cleaning, Grooming; Repetitive Routines; Need to Confess or Seek Reassurance; Re-experiencing the Event in Flashbacks or Nightmares; Hyperactive Startle Response; Emotional Numbing HEAD TRAUMA History Head Injury; Memory Impairment; Cognitive Impairment; Speech Impair; EATING DISORDER PSYCHOTIC Poor Focus and/or Organization; Personality Change; Uncharacteristic Impulsivity; ANOREXIA Restricting Food; Refusal to Maintain Body Weight; Stopped Menstruating. BULIMIA Binge Eating; Purging (vomiting, laxatives, diuretics, enemas, fasting or exercise). Delusions; Hallucinations; Disorganized Speech; Disorganized Thought or Behavior. IMPULSE CONTROL TICS INATTENTION Diminished Focus and Attention; Not Follow Through on Tasks; Poor Organization. HYPERACTIVITY Fidgets; Often On The Go or Driven by a Motor ; Inappropriately Runs & Climbs; IMPULSIVITY Often Interrupts or Intrudes on Others; Difficulty Awaiting Turn; Blurts Out Answers. OPPOSITIONAL Oppositional & Defiant; Argues with Adults; Loses Temper; Annoys People. Vocal Tics; Motor Tics.

7 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 7 GENERAL MEDICAL HISTORY 1. Is your child? Right Handed Left Handed Use Either Hand 2. Has your child had a physical exam in the last year? 3. Please review the following list of medical problems and circle any problem this child has had. For each circled problem, please give details on the reverse side of this page. Anemia Asthma Concussion Convulsion Seizure or Epilepsy Eczema (winter dry skin) Encephalitis Frequent Ear Infection Head Injury Hearing Problem Hyperthyroid Measles Meningitis Migraine Headache Pneumonia Poisoning or Overdose Psoriasis Salmonella infection Tremor Urinary Problem Vision Problem For questions 4 9, if necessary, continue on the reverse side of this page. 4. Has this child had an operation? If yes, describe the reason for each operation and give the age: 5. Has this child ever been hospitalized for medical reasons other than for an operation? If yes, described the reason for admission and give the age: 6. Has this child ever been to the emergency room or treated by a physician because of an accidental injury? If yes, describe each accident and give the age: 7. Has this child ever experienced a head injury, concussion or been unconscious? If yes, how many times: Describe the circumstances, and give the age: 8. For Males: Has this boy reached puberty (growth body hair, shaves, growth spurt)? 9. For Females: Has this girl begun to menstruate? If yes, at what age did she begin:

8 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 8 Past Medical History: Please list all medical conditions your child has experienced which have been the subject of medical evaluation and/or treatment. Include any additional information for affirmative responses to questions 3 9. Please list in chronological order (first to last), and include the Medical Problem, at what Age the problem became the subject of concern or treatment, the type of Treatment rendered (medication, surgery, physical therapy, etc) and the Outcome, whether the problem is now resolved or treatment is ongoing. Medical Problem Age Treatment Outcome

9 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 9 CHILD DEVELOPMENTAL QUESTIONNAIRE PRENATAL AND BIRTH HISTORY Please answer the following questions to the best of your knowledge. 1. Were there any problems during the pregnancy? 2. Were there any problems during the delivery? Note: The following questions would best be answered by the natural mother of this child. If she is not available, the informant should answer questions as best as he/she can. 3. If the natural mother is not available, please state why: 4. How old was the mother when this child was born: 5. How old was the father when this child was born: Yrs. 6. Did you have any of the following during your pregnancy with this child? If yes, state the circumstances, the specific drugs (if any) taken and the trimester in which the following occurred (1-first, 2-second, or 3-third). Yrs. Morning Sickness Bleeding from the Vagina Premature Contractions Swelling of face, hands or ankles High Blood Pressure Incompatible Rh factor Toxemia Rubella Diabetes Anemia Serious Injury Emotional Problems Other Illness X-rays Blood Pressure Pills Tranquilizers or Sedatives Medication for Anxiety Medication for Depression Medication for Nausea Antibiotics Water Pills (diuretics) Medication for Pain Medication to Prevent Miscarriage Medication for Weight Gain Thyroid Medication Circumstance Name of Drug Trimester

10 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page During your pregnancy with this child, were any of the following substances taken? If yes, state the duration of use and the trimester(s) in which it occurred (1-first, 2-second, or 3-third). Coffee 3 or more cups per day Cigarettes - more than 10 per day Alcohol Marijuana Speed or Methamphetamine Cocaine or Crack LSD or other Hallucinogen Other Illicit Drugs Name of Drug Duration (weeks) Trimester 8. Was amniocentesis performed (a sample of fluid was taken from the womb)? 9. Did any of the following things occur at or following the delivery of this child? Premature delivery (more than 2 weeks early) Late delivery (more than 2 weeks overdue) Labor was induced by drugs Caesarean section was performed before onset of labor Caesarean section was performed after onset of labor General anesthesia was used (mother was unconscious) Local anesthesia was used (spinal block) Breech delivery (buttocks first) Use of forceps Cord around the neck Blue at birth Slow heart beat Didn t breathe at first Infant had seizure fits or convulsions Infant had jaundice (yellow in color) Infant required oxygen Infant required blood transfusion Infant was placed in an incubator Twins or multiple birth 10. Delivery occurred at weeks of pregnancy? 11. How long was labor: 2 hours or less 3-12 hours hours more than 24 hours 12. At birth, what was this child s - weight: / length: lbs. ozs. inches 13. How soon after the delivery did you get to hold, feed or play with this child in a usual way: The first day 2 7 days 8 or more days after birth 14. Did this child stay in the hospital after you left? If Yes, how long to go home? Under 2 weeks 2 4 weeks 5 10 weeks Over 10 weeks

11 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 11 FIRST MONTHS Note: The following questions pertain to the first few months of this child s growth up to about six months old. 1. Was this child breast fed? If yes, how long? Less than 1 month. 1 3 months. 3-6 months 6 9 months months. More than 12 months. 2. Did this child like to be held? Yes Somewhat No 3. Did this child develop predictable sleeping habits? Yes Somewhat No 4. Did this child sleep easily? Yes Somewhat No 5. Did this child develop predictable eating habits? Yes Somewhat No 6*. How difficult did you find this child to care for? Very Somewhat Not 7. Was this child overly active? Yes Somewhat No 8. Was this child easily upset by sights and sounds? Yes Somewhat No 9. Did this child fuss and cry a lot? Yes Somewhat No 10. Was this child difficult to comfort? Yes Somewhat No 11. Was this child diagnosed as having colic? Yes Somewhat No SIX MONTHS TO TWO AND ONE HALF YEARS Note: The following questions pertain to the time after the first months of life to age 2-1/2 years. 1. Was there any known Child Abuse or Neglect? If yes, which: Neglect. Physical Abuse. Sexual Abuse 2. Did child maintain predictable sleep & eating habits? Yes Somewhat No 3. Did this child make effective eye contact? Yes Somewhat No 4. Did this child smile socially? Yes Somewhat No 6*. Did this child reach out and prepare to be picked up when approached by mother? 7. Did this child react unusually to light, sound or smell? Yes Somewhat No 8. Did this child walk unusually on his/her toes? Yes Somewhat No 9. Did this child repetitively flap hands or rock his/her body? Yes Somewhat No

12 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 12 DEVELOPMENTAL MILESTONES Note: For each of the following events in this child s development, indicate the age at which it happened and whether you felt this was early, on time or late for a child to be learning this skill. Check Not Applicable (N/A) if the skill has not been learned yet. 1. When did this child: Walk with assistance Walk without assistance Speak first words Speak 2 3 word phrases or sentences Speak such that most people understand Eat with utensils Understand names of objects Obey verbal commands 2. When did this child: Get dressed by him/herself Tie shoelaces Ride a 2-wheel bike w/o training wheels First achieved daytime urinary training First achieved nighttime urinary training First achieved daytime bowel training First achieved nighttime bowel training. Age - yrs N/A Early On Time Late Age - yrs N/A Early On Time Late 3. Has bed wetting stopped? Yes Somewhat No 4. Did this child begin bed/pants soiling a year or more after bowel training was complete? 5. In general, during early childhood (2-1/2 to 5 years) was this child (check one)? Note: Indicate how difficult or easy the following activities were for this child to learn and how well he/she performs them now. If the skill was never attempted for whatever reason (handicap, child is too young) check Not applicable (N/A). Eat with utensils Get dressed by himself Do buttons and zippers Tie shoes Print Letters Draw Play with Legos Fine hand work puzzles, models Swim Play soccer, baseball or football Tell time Count money Recognize numbers Recognize letters Easy LEARNING Not too Diff Pretty Diff Very Diff Very well PERFORMING Well Not well Poor or unable n/a

13 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page Does this child ride a bike without training wheels? If no, is it because this child (check one): Isn t ready yet too young Just couldn t learn Falls off Is afraid of heights 7. Does this child play well in group games? Yes Somewhat No If no, is it because this child (check one): Lacks coordination Can t take turns Gets confused by the rules Gets over stimulated and uncontrolled Doesn t pay attention - daydreams Other PARENTING AND DISCIPLINE 1. Please list any other person besides the parents, who will be involved in disciplining the child: Person Age Relationship to Child 2. For children age 12-years or younger, check any of the following disciplinary techniques that are used in the rearing of this child. Star or Behavior Chart Style of rewarding a child for a particular behavior: Praise Special Privilege Reward - Money Special Time or Outing with Parent or Other Style of punishing a child for a particular behavior: Discussing the Inappropriate Behavior Time Out Removal of a Privilege Spanking TEMPERAMENT Note: Temperament is a complex concept, but an important one for the purpose of this evaluation. Temperament may be thought of as the style of behavior a child usually exhibits. A child s Temperament may be understood according to nine dimensions or variables, eight of which are listed and described below. These variables are determined partly by genetics, and partly by the environment. They may correlate with emotional and behavioral styles that are important for the clinician to understand and may have significant implications for this evaluation. If any aspect of the following questions are difficult to understand or to answer, please let your clinician know and the questions will be discussed during the initial visit.

14 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page Activity Level This dimension or variable considers the motor component (physical activity level) present in a child s usual functioning. Please describe your child s Activity Level (circle one): Low Normal High Very High 2. Rhythmicity This dimension or variable considers the predictability of such biological functions as hunger, feeding patterns, elimination (going to the bathroom), and the sleep-wake cycle. Regular and Predictable would indicate that the child developed a predictable pattern of biological functions. Irregular and Unpredictable would indicate that the child developed an unpredictable pattern of biological functions. Please describe your child s Rhythmicity (circle one): Regular and Predictable Irregular and Unpredictable 3. Approach or Withdrawal This variable considers the child s the response to a new stimulus (any situation that is new to the child), such as a new food, toy, or person. A Positive Response would mean the child is not disturbed by the new stimulus, and may be happy, curious or otherwise positively affected. A Negative Response would mean the child was disturbed by the new stimulus, and may become unhappy, fearful or agitated, or would otherwise negatively affected. Please describe your child s Approach or Withdrawal response to a new situation (circle one): Positive Response Negative Response 4. Adaptability This dimension or variable considers the speed and the ease with which the child s current behavior is able to be modified in response to parent s or other s directions, encouragement or punishment. In other words, does the child s behavior respond or adapt readily to these interventions, or does it adapt minimally or not at all. Please describe your child s Adaptability (circle one): Usually does not Adapt Slow to Adapt Quick to Adapt 5. Intensity of Reaction This dimension or variable considers the amount of energy used in mood expression. A Low Intensity Reaction would describe a child for whom very little energy is used during the usual expression of mood. High and Very High Intensity would describe a child for whom much or very much energy was used. Please describe your child s Intensity of Reaction (circle one): Low Normal High Very High 6. Quality of Mood This dimension or variable considers the child s usual quality of mood associated with behavior, which may be pleasant, joyful, friendly behavior as contrasted with unpleasant, crying, unfriendly behavior. Please describe your child s predominant Quality of Mood (circle one): Positive Negative 8. Distractibility This dimension or variable considers the effect that external stimuli usually has in interfering with or altering the child s ongoing behavior. A choice of Distractible would describe a child whose ongoing behavior is easily interfered with by external stimuli. Please describe your child s Distractibility (circle one): Very Distractible Distractible Not Very Distractible 9. Attention Span and Persistence This dimension or variable considers the length of time a particular activity is pursued by the child (attention span) and the continuation of an activity in the face of obstacles (persistence). Please describe your child s Attention Span and Persistence (circle one): Low Normal High Very High Temperament Clusters: Easy Difficult Slow to Warm Up Mood Positive Negative Rhythm Regular Irregular Adaptability Adaptable Slow to Adapt Gradual Intensity of Reaction Low Intensity High Intensity Mild Response to Novelty Positive Negative Negative

15 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 15 SCHOOL HISTORY 1. What is the child s current grade level (circle one): K This child is currently in: Elementary School Middle School High School Public School Private School Charter School Religious School Which Denomination: ELEMENTARY SCHOOL: City Grades Attended Performance MIDDLE SCHOOL: City Grades Attended Performance HIGH SCHOOL: City Grades Attended Performance 3. In general, how has this child s academic performance (grades) been? Below Average Average Above Average 4. Has this child ever been suspended for disciplinary reasons: 5. Has this child been evaluated for Special Education: If yes, when was the initial Individualized Educational Plan (IEP) performed? 6. Was the child accepted for Special Educational Services? If no, is there a 504 Plan? 7. If the child is in Special Education, when was the most recent IEP Meeting? If your child has an Individualized Educational Plan, it is important that you bring a copy of all original academic assessment records AND a copy of the most recent IEP with you to your child s initial appointment. PAC*-Adolesc-DemoMedDev

16 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 16 LEGAL HISTORY 1. Has this child ever experienced legal trouble or prosecution for any reason: If yes, please provide a brief description of the issue: 2. Has this child ever been convicted of a DUI or Wet Reckless for any reason? If your child has legal issues and/or is on diversion, probation, or is a dependent or ward of the court, it is important that you bring a copy of any Court Orders AND contact information for your child s probation officer, attorney or guardian ad litem with you to your child s initial appointment.

17 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 17 DRUG & ALCOHOL HISTORY 1. Have you suspected that your child has a substance abuse problem? DRUG & ALCOHOL USE INVENTORY - Please thoroughly review the following drugs. Circle each drug your child is currently or has ever taken for whatever reason, even if it was taken just once. Include drugs used recreationally. Ever Used? Ever a Problem? Age/Year 1 st time/regular Use Use Past 6 mo Frequency/Amount Last Use Alcohol Yes No Yes No Marijuana Yes No Yes No Hashish Yes No Yes No Cocaine Yes No Yes No Crack Yes No Yes No Methamphetamine (crank) Yes No Yes No Amphetamine Yes No Yes No Ecstasy (MDMA) Yes No Yes No Heroin Yes No Yes No Speedball Yes No Yes No Methadone Yes No Yes No Vicodin Yes No Yes No Percodan Yes No Yes No Codeine Yes No Yes No Demerol Yes No Yes No Oxycontin Yes No Yes No Dilaudid Yes No Yes No Valium Yes No Yes No Xanax Yes No Yes No Rohypnol Yes No Yes No Seconol (reds) Yes No Yes No Quaalude Yes No Yes No Other Barbiturates (downers) Yes No Yes No Sleeping Pills Yes No Yes No Soma Yes No Yes No LSD Yes No Yes No Mushrooms Yes No Yes No Mescaline (Peyote) Yes No Yes No PCP (Angel Dust) Yes No Yes No Ketamine (Vitamin K) Yes No Yes No Nitrous Oxide Yes No Yes No Glue Yes No Yes No Gasoline Yes No Yes No Nicotine Yes No Yes No Other Yes No Yes No

18 CHILD DEMOGRAPHIC, MEDICAL & DEVELOPMENTAL QUESTIONNAIRE Page 18 PLEASE HAVE YOUR CHILD/ADOLESCENT COMPLETE THE FOLLOWING: CRAFFT Questions. No. Questions Yes/No 1 2 Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs? Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? 3 Do you ever use alcohol or drugs while you are by yourself (alone)? 4 Do you ever forget things you did while using alcohol or drugs? 5 Do your family or friends ever tell you that you should cut down on your drinking or drug use? 6 Have you ever gotten into trouble while you were using alcohol or drugs? PAC*-Adolesc-DemoDevTx *