CHILD/ADOLESCENT BACKGROUND AND HISTORY QUESTIONNAIRE. Form Completed By Today s Date
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1 CHILD/ADOLESCENT BACKGROUND AND HISTORY QUESTIONNAIRE Child s Name Date of Birth Home Address_ Home Phone Form Completed By Today s Date Custody Status (check all that apply): Child lives with both biological parents Child lives with biological mother Child lives with biological father Child lives with adoptive mother and father (Age at adoption ) Child lives with foster parent(s) Child lives with grandparent(s) Child lives with other relative(s) Who lives in the home with your child/adolescent? Name Relationship to child Date of birth Are there any siblings not living in the home? Name Relationship to child Date of birth If parents are divorced or unmarried, what is the frequency of contact between your child/adolescent and the non-custodial parent?
2 Pregnancy and Delivery Did the child s birth mother smoke during pregnancy? YES Did the child s birth mother drink alcohol during pregnancy? YES Did the child s birth mother use drugs during pregnancy? YES Did the child s birth mother receive prenatal care during pregnancy? YES Please describe any complications with the pregnancy or delivery: Developmental Milestones Please indicate the approximate age at which your child/adolescent achieved each of the following developmental milestones: Developmental Task First words Crawled Walked without support Toilet trained Age Medical History Name and address of child s pediatrician or primary care physician: Are your child s immunizations up to date? YES Has your child been diagnosed with any of the following medical conditions? Asthma Allergies Cancer or blood disease Cystic Fibrosis Diabetes Headaches/Migraines Obesity Kidney disease Liver disease Gastro-intestinal condition Other (Please specify ) If yes to any of the above conditions, please describe the treatment regimen:
3 Does your child have any food or drug allergies? YES DON T KW If yes, specify_ Do you have any concerns with your child s dietary habits? YES If yes, specify _ Has your child/adolescent had a significant appetite change in the last month? YES Comments: Do you have any concerns with your child s sleeping patterns? YES If yes, please specify Has your child/adolescent had a significant change in sleep patterns in the last month? YES Comments: Behavioral/Emotional Health History Please indicate any past or present behavioral or emotional concerns: Past Present Biting Bed wetting Daytime toileting accidents Inattention Hyperactivity Fears/Phobias Sad/Depressed mood Eating concerns extreme pickiness Eating concerns strict dieting Eating concerns overeating Eating concerns bingeing and purging Eating concerns excessive exercise Learning problems Difficulty getting along with peers Social skills problems Victim of teasing or bullying Bullying other children Arguing with adults Physically harming other people or animals Threatening physical harm to anyone Fire starting
4 Past Present Running away from home Talking about or attempting suicide Cutting or mutilating body Obsessive thoughts and/or actions Drug or alcohol use Motor tics Stuttering Victim of physical abuse Victim of sexual abuse Victim of emotional abuse Witnessed domestic violence Other significant trauma (Please specify: ) Other concerns (Please specify: Has your child had previous outpatient psychological treatment? YES Name of therapist Dates of treatment Reason for treatment Has your child had previous inpatient psychological treatment? YES Name of program/facility Dates of treatment Reason for treatment Has your child ever had a psychological or psycho-educational evaluation? YES If yes, what were the results?
5 Is your child/adolescent currently taking any medication (prescription, over-thecounter, vitamins, herbs, or supplements) for emotional, behavioral, academic, or medical reasons? Medication Dosage Reason Significant Events Please check any significant events your child/adolescent has experienced: Change of school Move to a new place Loss of someone close to the child/adolescent Serious illness or injury to a family member or friend Death in the family Frightening experience for the child/adolescent Divorce or separation Change in family structure (someone moves in/out of home, blending of families) Education Where does your child/adolescent currently attend school? What grade is your child/adolescent in? Has your child/adolescent ever skipped a grade? YES Has your child/adolescent ever repeated a grade? YES Does your child/adolescent receive any special academic services (e.g. special education, tutoring, gifted program)? YES If yes to above question, please describe:
6 Please describe any academic or school-related concerns that you have with regard to your child/adolescent: Parents highest grade completed: Mother Father Family Health History Have any family members (siblings, parents, aunts, uncles, cousins or grandparents) been diagnosed or treated for a mental health or substance abuse problem? YES DON T KW Please explain if yes to above question: Present Concerns Name and address of referring person What are your biggest concern(s) regarding your child/adolescent? What are your child s strengths? Other Comments:
7 Thank you for completing this questionnaire.
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