Lisa Karabelnik, MD 68 South Main Street; Suite 200 West Hartford, CT P (860) F (860) Patient Name (Last, First, Middle)
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1 Lisa Karabelnik, MD 68 South Main Street; Suite 200 West Hartford, CT P (860) F (860) Patient Name (Last, First, Middle) Date of Birth Significant Childhood History Pregnancy and Delivery: Infancy and Toddlerhood: First sat unsupported on a flat surface First stood alone First 3 or 4 steps without holding on First 3 or 4 words with meaning, other than mama, dada First 3 or 4 words to form first sentence Was your child considered slow, average, or fast in comparison to siblings, other children? Age when control training was begun Age when occasional accidents no longer occurred Difficulties in bowel/.bladder training Have other members of the family had difficulty with bedwetting/soiling? If so, who School History: Highest level of education and if attended professional program/higher education program where and when did you graduate with what degree: Current occupation (part time/fulltime): 1
2 Did you have any difficulty during school? ( Y / N ) If so, please elaborate. Hyperactive (very active) (y/n) Limited attention span (y/n) Limited concentration (y/n) Easily distractible (y/n) Disorganized (y/n) Destructive (y/n) Dependent (y/n) Easily frustrated (y/n) Overly talkative (y/n) Lacks self-confidence (y/n) Health History: This section concerns general health State of general health: Health problems within the past year? (y/n) Breathing difficulties (asthma)? (y/n) Headaches (y/n) If yes, when, how often, affect sight, time of day, what makes better or worse? Stomachaches (y/n) Excessive vomiting, belching (y/n) Eating problems home or school (y/n) Sleeping difficulties (y/n) Sleepwalking (y/n) Nightmares or night terrors (y/n) which one? Enuresis (bedwetting or daytime accidents) (y/n) Painful urination, dribbling, blood in urine(y/n) Encopresis (soiling accidents) (y/n) Smearing (y/n) _ Activity range (overactive, normal, underactive) Stay still if expected to (y/n) How long? Doing what? Preferred hand/foot (right/left) Coordination (very coordinated, average, clumsy) Tic and habitual mannerisms: Twitches face and/or shoulders (y/n) Blinking(y/n) Lip smacking(y/n) Other tics(y/n) _ Thumb-sucks(y/n) Nail biting(y/n) _ Head banging(y/n) Sucks tongue(y/n) Favorite soft toy or blanket(y/n) Episodic Disorders: Fainting spells(y/n) Convulsions(y/n) 2
3 Petit Mal seizures(y/n) Blinking, staring, or absence attacks(y/n) Grand mal seizures(y/n) Allergies: Name and Address of Primary care provider: Phone number of primary care provider: Any serious illnesses/injuries(y/n) Meningitis, encephalitis, head injury, skull fracture, concussion, periods of unconsciousness, coma (y/n) (circle) when? Hospitalized ever? (y/n) Emergency Room visits (y/n) Why? Medications: (name/dose/for what illness) Current: Past Personality: Emotions and Moods (Please circle) Generally speaking, my child (is): Happy or sad Full of worries or secure Cries easily or holds it in Many rituals and/or compulsions Irritable or complacent Easygoing or nervous Stubborn or submissive Peer Relationships: How do you get along with others? Do you make friends easily? (y/n) Have many friends? (y/n) Relationship with siblings: List names/ages/any health/behavioral/or educational issues: Also, whether or not you get along with them. 3
4 Relationships: Please describe your relationship with your parents. How often do you see/communicate with them? Do you have a significant other? How long have you been together? How would you describe your relationship? What do you do with your significant other? Do you have children? ( Y / N ) Names and ages/grades (if applicable): Do your children present any challenges for you: Who participates in household chores? What arrangements are made for free time? Family History: Is there anyone in the immediate or extended family: (Circle and identify family member, e.g. grandparent, mother, sister, aunt, etc. and which side of the family.) With mental disorder (y/n) Who received psychiatric treatment (y/n) Taking tranquilizers (y/n) Taking sleeping pills (y/n) With sleeping problems (y/n) Who has been hospitalized for emotional problems (y/n) Who has ever tried to kill themselves (y/n) Who has ever committed suicide (y/n) With a drinking problem (y/n) With arrests for drunken driving (y/n) With drug abuse problems (y/n) With difficulty with the law (y/n) Who has served time in jail (y/n) With gambling issues (y/n) 4
5 With depression (y/n) With cycles of happiness (elation) and sadness (y/n) With fatal disease (y/n) With anxiety (y/n) With learning issues (y/n) Who has been diagnosed as on the autistic spectrum (y/n) Formal Evaluations: Has you ever had formal educational/psychological testing? (y/n) Dates, if known: Where was this done? (i.e. name of school, clinic, provider, etc.) Vision: Has difficulty seeing ever been suspected? (y/n) Have glasses been prescribed? (y/n) Hearing: Has hearing difficulties ever been suspected? (y/n) Ever had a hearing test? (y/n) If yes, date and results: Where was this done? What else would you like me to know that has not been asked? What questions do you have for me? What do you hope this evaluation will accomplish? 5
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