PAMF Developmental Behavioral Pediatrics ... - Sutter …
Developmental-Behavioral Pediatrics Intake Form
IDENTIFICATION
Patient (Child) Name:
Nickname:
Page 1 of 12
Female Male (circle one)
Date of Birth: / /
.
Best Phone Number:
Other Phone Number(s):
Email Address:
Mobile Home Work (circle one)
Parent Name: Mother Father Guardian
Parent Name: Mother Father Guardian
Street Address:
City:
Zip Code:
Person completing this form:
Preferred Language Parent:
Child:
Date form completed: MM/DD/YY
**Please call (408)523-3960 at least two (2)
/
/
.
days before the appointment to request a
language interpreter.
Please take the time to complete this intake form to the best of your knowledge. There is space
at the end for additional comments or thoughts. Submitting this form before the appointment
date will help our providers better serve you and your child.
CHIEF CONCERNS: What is your biggest concern and/or goal for this appointment?
2577 Samaritan Drive #725 San Jose, CA 95124 P: 408-523-3960 F: 408-523-3625 or 408-523-3042
Page 2 of 12
Who suggested this child be seen by the doctor for attention, school, or behavior problems?
How long have you been concerned about the child's behavior?
Please describe the child's strongest areas at home:
Please describe the child's weakest areas at home:
Please X check any of the following developmental/behavioral issues your child has had in the past. CIRCLE the issues you fell are still ACTIVE.
Talking
Little/no interest in people
Expressing wants/needs
Not affectionate with people
Having a back and forth
Poor eye contact
conversation
Does not respond to name
Stuttering
Shy with strangers
Strangers understanding the
Bashful with other children
child's speech
Refusal to go to school
Following directions/instructions
Play immature for age
Involuntary movements
Problems with routine changes
Stiff or rigid arms/legs
Rigid behaviors
Loose or floppy muscle tone
Head banging or self-injurious
Clumsy/poor coordination
behaviors
Difficulty writing
Extreme restlessness
Motor tics (e.g. blinks, shrugs)
Overactive/impulsive behavior
Vocal tics (e.g. grunts, cough)
Inattention/poor focus/easily
distracted
Colic Anxiety
Overreaction to sights or noises
Sadness
Very high tolerance for pain
Temper Tantrums or Oppositional
Very low tolerance for pain
behavior
Other:
Irritability (crying often and easily)
Difficulty getting consoled
Please elaborate on any of the checked boxes above:
What do you believe is the root reason(s) for these concerns/issues?
What have you done to address the above concerns/issues at this point?
2577 Samaritan Drive #725 San Jose, CA 95124 P: 408-523-3960 F: 408-523-3625 or 408-523-3042
Page 3 of 12
INTERVENTION/THERAPEUTIC HISTORY Has your child ever received a developmental and/or behavioral assessment by a medical (not primary
care provider) or psychological specialist (i.e. PhD/PsyD training)? Yes No Unsure
If yes, who and when (year)?
If yes, what were the results/outcomes?
Has your child ever received early intervention under 3 years of age (Early Start, Part C, IFSP)?
Yes No Unsure
Please (x) the following interventions/therapies your child received in the past.
Speech/Language Behavioral (e.g. ABA, psychological) Social Skills
Occupational Physical Parent training/coaching Other:
Are there any professionals (MDs, psychiatrist, social workers, and/or therapists) currently
involved in this child's care? Yes No
If yes, please specify:
Has this child ever been diagnosed with ADHD or ADD in the past? Yes No
If yes, when?
Where was the evaluation completed?
Has this child ever taken medication for ADHD or ADD in the past? Yes
No
If yes, Name:___________________ Dose:______________ Date started:__________________
Were you satisfied with the medication's effect on this child's symptoms? Yes No
Is this child currently taking any vitamins or herbal supplements? Yes No
If yes, please specify:
FAMILY INFORMATION & HISTORY
The following people live with the child:
Relationship
Name
Highest Education
Occupation
Is your child adopted? Yes No Is your child in foster care? Yes No Are the parents separated? Yes No
2577 Samaritan Drive #725 San Jose, CA 95124 P: 408-523-3960 F: 408-523-3625 or 408-523-3042
Page 4 of 12
Are the parents divorced? Yes No
If yes, who has legal custody of your child?
Do you have family or social support locally? Yes No
Is there anything unusual about this child's living arrangement that you would like to discuss with the
child's doctor? Yes No
Have there been significant stress lasting over one year? Yes No
Have there been any recent (< 1 year) significant stress producing events?
Yes No
Is your child exposed to frequent arguing between parents or adults at home?
Yes No
Please (x) the appropriate boxes if there is a history of the following conditions in child's family (biological
relatives only):
Mother
Father
Brother(s)
Sister(s) Other relatives
Speech Language
problems
Learning or reading
difficulties
Hyperactivity/Impulsivity
ADHD/ADD (attention
problems/hyperactivity)
Autism Spectrum
Disorder
Intellectual Disability (low
IQ)
Drug/alcohol abuse
Depression
Anxiety/Compulsions
Neurologic problems
Bipolar Disorder/ Manic
depression
Schizophrenia/Hallucinati
ons
Cardiac problems or
sudden death?
Any family history of early
cardiac deaths ................
................
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