Please list al other people living in the household:



CHILD MEDICAL / SOCIAL HISTORY QUESTIONNAIREThis questionnaire asks you to respond to a series of questions about your child and family. All of the information you provide will be kept confidential. If you have any questions, please call at 204-6970.Child’s Name ___________________________________Birth Date ______/______/_______Address _________________________________________ Home Phone _____-_____-_______ _________________________________________ Work Phone ____ -_____-_______ Is it all right to call you at work? _________________________________________ Yes ______No ________Your Name _______________________________________ Today’s Date _____/_____/_______Who referred your child to my office? ____________________________________________________Is it okay to thank this person for the referral?YESNOIn your own words, what are you hoping will be accomplished by our seeing your child?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Has this child had a previous psychological evaluation? Yes _____No _____If so, where and when? __________________________________________________________PLEASE INCLUDE COPIES OF ANY PREVIOUS EVALUATIONS.FAMILY HISTORYFather’s Name ______________________________________ Birth Date ______/______/_________Education _____________________________________________________________________Occupation ______________________________ Employer ____________________________Mother’s Name _____________________________________Birth Date ______/______/_________Education _____________________________________________________________________Occupation ______________________________ Employer ____________________________Parent’s Current Marital Status: Married _____Separated ____Divorced ____List any legal custody issues involving this child _________________________________________________________________________________________________________________Please list all other people living in the household:NAMEAGERELATIONSHIP TO CHILD*GRADE IN SCHOOL* List present grade or highest grade completed.List any other people who are with the child a significant amount of time.Name: ________________________________________________________________________RELATIONSHIP (Grandmother, friend, etc.) __________________________________We are interested in whether anyone in the family , other than this child, has or has had any of the conditions listed. Please put an X in the column of the family member(s) who have or have had each problem.CHILD’SMOTHERCHILD’SFATHERCHILD’SBROTHER(S)CHILDSISTER(S)OTHER(specify)Hyperactive as a childRepeated a grade in schoolSpeech ProblemsSeizuresMental RetardationBehavioral Problems inChildhoodIn trouble with the lawDepressionBipolar / Manic- DepressionOther emotional problemsDrinking Problem or Drug AbuseSerious health problemsOther serious problemsDEVELOPMENTAL HISTORYChild’s birth weight ______lbs., ______oz. Length of pregnancy ______weeks.Were there medical problems during pregnancy? ______No ______YesIf so, what: _____________________________________________________________Were there medical problems during birth? ______No ______YesIf so, what: _____________________________________________________________Were there medical problems during the child’s first year? ______No ______YesIf so, what: _____________________________________________________________Please record the approximate age at which your child first did the following:Approximate Age Not Yet Don’t Remember AchievedWalked without help………. ________ ________ ________Spoke first words other than “mama or “dada”………. ________ ________ ________Spoke in 2-3 word sentences………. ________ ________ ________Toilet trained – daytime………. ________ ________ ________Toilet trained – nighttime………. ________ ________ ________Rode bicycle without training wheels………. ________ ________ ________Overall, do you feel your child has developed at a SLOW,NORMAL, orRAPID RATE?MEDICAL HISTORY Current health (poor, good, excellent): ____________Approximate height / weight: _____________Child’s Physician: ________________________________Date of last exam:______________________Is it okay to contact the physician to coordinate care?YESNOHas your child ever had any of the following:Hospitalized ? ____No ____YesAllergies?____No ____YesHead injury?____No ____YesAsthma?____No ____YesSeizures?____No ____YesVision problems? ____No ____YesPoor coordination? ____No ____YesHearing problems? ____No ____YesMany ear infections?____No ____YesSpeech problems?____No ____YesDifficulties with eating?____No ____YesDifficulties with sleeping?____No ____YesPlease list any significant illnesses, operations, conditions that I should be aware of: _______________________________________________________________________________________________________________________________________________________________________________Illnesses for which the child is currently treated: __________________________________________________________________________________________________________________________________Current physical problems your child reports: _______________________________________________Medications child is currently taking and the dosage: _______________________________________________________________________________________________________________________________In the past six months, has there been a change in your child’s weight, appetite, or sleep?If yes, please explain. __________________________________________________________________________________________________________________________________________Any current sleep issues? ________________________________________________________________Any current eating issues? _______________________________________________________________ Do you have knowledge or think your child is using drugs/alcohol?NOYESHas your child ever been physically or sexually abused? NOYES Has your child ever been involved in any type of professional mental health treatment?NOYESIf yes, please list the name of the therapist, duration of therapy, the purpose of therapy, and dates.__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________EDUCATIONAL HISTORYCurrent School: _______________________________________________________________________Current Grade: ________________________School District: ________________________________ Teacher’s Name: ______________________Counselor’s Name: _____________________________To the best of your knowledge, at what grade level is your child functioning at: Reading? _____________Spelling? _____________Arithmetic? _____________Does your child have trouble with handwriting? _____No _____YesHas your child ever repeated a grade? ______No ______YesIf so, which grade(s)?_____________________________________________________________What subjects does your child do well in? _________________________________________________________________________________________________________________________________ What subjects does your child do poorly in? _______________________________________________________________________________________________________________________________What, if any, special educational (e.g., IEP) services does your child receive? _____________________________________________________________________________________Is your child being tutored privately? _____No _____Yes; Tutored before? _____No _____YesHas your child had special testing or evaluations in school over the past year or two?_____No _____Yes _____Don’t KnowDoes the teacher complain about your child’s behavior in school? _____No _____YesIf so, about what? _______________________________________________________________Any attendance problems? _____No _____Yes If yes, why? _________________________________Is finishing homework a problem? ______No ______Yes ______No homework givenDo you believe your child is hyperactive or has problems with attention and concentration?_____No______YesBEHAVIORAL HISTORYList what your child likes to do for fun or free-time activities (e.g., piano, soccer, models, computers):1.______________________________2. ______________________________3. _____________________________4. ______________________________How much TV/video/Xbox/Wii/ Playstation-type time is spent during a typical weekday? __________hrs.During the weekend? __________hrs.List any chores your child now has:____________________________________________________________________________________________________________________________________Is getting them done typically a problem? ______Yes ______NoMISCELLANEOUSWhat do you feel is your child’s main problem(s)? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What do you think caused your child’s problem(s)? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________How serious do you think your child’s problem(s) is/are at this time?No Problem _____ Minor Problem _____ Moderate Problem _____ Serious Problem _____4.What have you been told by doctors, teachers, or others about your child’s problem(s)? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________5.What do you like about your child? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Compared to other families, the stress level of your home usually is?______ About the same______ Less than most______Greater than mostPlease list any unusual and/or traumatic events in your child’s life that you feel may have impacted upon your child’s development and / or current functioning (e.g., any death in the family, divorce, illnesses, birth of a sibling, frequent school changes, moves, etc.)INCIDENTCHILD’S AGECOMMENTS1. _________________ _________________________________________________________________________________2. _________________ __________________________________________________________________________________3. _________________ ___________________________________________________________________________________4. _________________ ___________________________________________________________________________________5. ________________ ____________________________________________________________________________________Please list below any additional information or comments you wish to share about your child or your family. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Page 6Listed below are items about children’s behavior. Decide how much concern you have about each area over the last few months. Mark your choice by placing a checkmark in the appropriate column to the right of each item.BEHAVIORAL AREAHow Much of a Problem?NoneSomeVery MuchEating ProblemsSleeping ProblemsFears or WorriesSpeech ProblemsWets or Soils SelfClingy, DependentTemper TantrumsMany Physical ComplaintsClumsy or Poor CoordinationSocially ImmatureNervous Twitches or TicsUnhappy ChildAngry ChildBragsShynessProblems with FriendsAlcohol/Drug AbuseFights with Brother(s) / Sister(s)Acts without ThinkingOveractiveShort Attention SpanSexual ProblemsStealingLyingPerfectionistOppositional or Defiant ArguesWhines/CriesSuicidal Talk or ThoughtsLikes Being AloneOverweightLacks EnergyStrange IdeasStrange BehaviorOther (Specify)Page 7 ................
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