|
Please select "New Patient" or "Returning Patient".
|
|
|
New Patient
|
Returning Patient
|
|
History of Present Illness
|
|
|
Are there any changes or concerns since your last visit you would like to discuss?
|
|
|
For what reason did you make this appointment? Please list the top three concerns.
|
|
|
What age did these problems start?
|
Have you sought help for these problem(s) in the past?
|
|
Please list previous OUTPATIENT providers for mental health
|
Please list previous psychiatric diagnoses
|
|
List Previous Psychiatric Hospitalizations
|
|
|
Has psychological testing been done by the school or another provider? If yes, by whom?
|
|
|
Please list current medications, date started, reason started, and effectiveness.
|
Please list previous medications. List reason for failed meds.
|
|
|
|
|
Family History
|
|
|
Is the patient adopted?
|
Is the patient aware of their adoptive status?
|
|
Please list all persons living in the home with the child including name, age and relation.
|
Names of biological parents (if not previously listed)
|
|
Father - mental, physical illness, or substance abuse history
|
Mother - mental, physical illness, or substance abuse history.
|
|
Sibling(s) - mental, physical illness, or substance abuse history.
|
Other family - mental, physical illness, or substance abuse history.
|
|
Developmental History
|
|
|
Were their complications with the pregnancy?
|
Please list any pregnancy complications
|
|
Was the patient exposed to substances during pregancy?
|
|
|
Was the child carried to term?
|
How many weeks early?
|
|
Were there complications with the delivery?
|
Please list any delivery complications
|
|
Birth weight (lbs/oz)
/
|
Days child was in the hospital
|
|
Age child first walked
|
Age child said 2 words together
|
|
Age at potty training
|
The child's temperament was described as
• • •
|
|
Past and current discipline techniques
|
|
|
Medical History
|
|
|
Are immunizations up to date?
|
Please list any past surgeries
|
|
Date of last check up and results
|
Please list any current medical problems.
|
|
Does the patient have food or drug allergies?
|
If yes, please list food and or drug allergies
|
|
Is the pateint engaged in substance abuse?
|
If yes, please list any substances of abuse
|
|
Social History
|
|
|
Grade
|
Name of school
|
|
Academic performance
|
Is the child in regular classes?
• • •
|
|
Please list extracurricular activities
|
Has the child been suspended or expelled? How many times and for what reason(s)?
|
|
Does the child have friends? If so how many?
|
Does the family practice any specific religious belief system?
|
|
Has the patient been exposed to trauma including natural disasters, domestic violence or child abuse?
|
|
|
Please mark any symptoms that apply
|
|
|
Specific Symptoms
|
|
|
Has the patient experienced sadness for the last two weeks?
|
|
|
If yes, please select all that apply
• • •
|
|
|
Has the patient shown an increase in mood, activity or extreme irritability
|
|
|
If yes, please select all that apply
• • •
|
|
|
Does the patient worry frequently?
|
|
|
If yes, please select all that apply
• • •
|
|
|
Has the patient exhibited symptoms of a panic attack?
|
|
|
If yes, please select all symptoms that apply
|
|
|
Hyperventilation
• • •
|
Fainting/Dizziness
• • •
|
|
Pounding heart
• • •
|
Trembling
• • •
|
|
Sweating
• • •
|
Choking sensations
• • •
|
|
Nausea
• • •
|
Numbness/Tingling
• • •
|
|
Chest pain
• • •
|
Fear of dying
• • •
|
|
Fear of going crazy
• • •
|
Feeling detached from self
• • •
|
|
Feeling numb
• • •
|
Nightmares
• • •
|
|
Flashbacks
• • •
|
Startle response
• • •
|
|
|
|
|
Feel Fear or Anxiety Of:
• • •
|
|
|
Does the patient have trouble completing tasks
• • •
|
Can't pay attention
• • •
|
|
Fidgeting
• • •
|
Easily distracted
• • •
|
|
Interrupts others
• • •
|
Has too much energy or moves too much
• • •
|
|
|
|
|
Severe problems with social skills
• • •
|
Hear or see things others do not
• • •
|
|
Social anxiety
• • •
|
Has strange or false beliefs
• • •
|
|
Obsessive Compulsive Behavior
• • •
|
Attachment problems
• • •
|
|
Oppositional Behavior
• • •
|
Sensory problems
• • •
|
|
Eating problems
|
Conduct problems
• • •
|
|
Loss of bowel control
|
Bed wetting
|
|
Does the patient have at least 3 outbursts per week with irritability in between.
|
|
|
What do you hope will come out of the appointment?
|
Do you have information which you do not want discussed in front of your child?
|
