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

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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

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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

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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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