|
New Patient History
|
|
Please fill out this form prior to your appoinment, print a copy for yourself, and bring it with you to our first meeting. Not all fields are required, but please provide as much information as possible. The fields marked with (*) are required fields. |
 |
Today's Date * |
|
|
|
Patient Name * |
|
|
|
Date of Birth * |
|
|
|
Parents or Guardians |
|
|
|
Siblings |
|
|
|
Referred By |
|
|
|
Please tell me why you are seeking this evaluation at this time. * |
|
|
|
Please tell me about what you see as your child's strengths.
|
|
|
|
Please tell me about prior evaluations and treatments that your child has received.
|
|
|
|
Please tell me about any medications (psychiatric and other) that your child is currently taking, including how long he/she has been on the medicine, current doses, how well it is working and any side effects. |
|
|
|
What, if any, other psychiatric medications have been tried in the past? |
|
|
|
Tell me about your child's school situation. What grade and school, what type of classroom and supports are in place,what type of problems or concerns are occuring at school? |
|
|
|
Were there any health concerns or problems during the pregnancy, delivery or neonatal period? |
|
|
|
Birth Weight |
|
|
|
Child first walked at what age? |
|
|
|
Age Child first spoke in words? Sentences? |
|
|
|
Were there ever any concerns about your child's early development? Were Early Intervention Services ever recommended? |
|
|
|
Please tell me about any medical problems that your child has or has had in the past.
|
|
|
|
Has your child experienced any of the following?
|
Headaches or Migraines
Seizures
Tics
Head Injury
Chronic Pain |
|
|
Is your child allergic to any medications? If so, which ones and what are the reactions?
|
|
|
|
Please describe your child's sleep patterns. |
|
|
|
Has your child ever exhibited any of the following symptoms? |
Suicidal Thoughts
Suicide Attempts
Self Harm, Such as Cutting
Threats to Harm Others
Hurting Others |
|
|
Do you think your child may be using alcohol, tobacco, marijuana or other drugs? If so, please describe your concerns. |
|
|
|
Is there any family history of psychiatric illness or substance abuse? If so please describe |
|
|
|
Is there anything else that you think I should know about your child or the family that may be important in understanding him or her? |
|
|
