Child & Adolescent Patient History Questionnaire
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1 COLLEGE OF MEDICINE Jacksonville 6266 Dupont Station Ct Department of Psychiatry Jacksonville, Fl Child & Adolescent Phone Fax Date of Appointment: Chronologic Age: Today s Date: Child & Adolescent Patient History Questionnaire Child s Name: Nickname? Date of Birth: Mother s Name: Relationship: (step, adoptive, foster, etc) Address: Home and/or Cell Phone: Father s Name: Relationship: (step, adoptive, foster, etc) Address: Home and/or Cell Phone: Referred By: What Are Your Concerns About Your Child? When Did You Begin To Notice These Concerns? Additional Concerns: 1
2 Past Psychiatric History Has your child ever seen a psychiatrist? If so, please provide information about providers, dates, and treatment rendered. Has your child ever seen a psychologist? Has your child ever seen a therapist? Has your child ever been hospitalized for psychiatric reasons? If so, where and when? Please circle the behaviors below that pertain to your child. Nervous Hyperactive Temper tantrums Poor sleep Short attention span Cries easily Behavior problems Destroys property Easily frustrated Excessive fears Motor tics Bite nails Pulls hair Frequent headaches Frequent Fatigue/easily tired stomachaches Harms self (ie. Hurts others (hits, Overweight Perfectionist cutting) bites, kicks) Shy Does not follow rules Worries a lot Overly talkative Low self esteem Likes self Withdrawn/sullen Slow learner Demands attention Plays well with peers Irritable Trouble making friends Prefers to play alone Depressed/sad Legal problems Weird ideas/bizarre thoughts Running away from Vision problems Hearing problems Speech problems home Sexually active Alcohol use Drug use Tobacco use Legal Problems Head Injury Medications: Please list all medications or supplements taken by your child. Include psychiatric and medical medications. Medication 4. Dose (mg, units,ml, etc) 2 Doses per day (AM, twice daily, at bedtime, etc)
3 Past Primary Care Physician: Clinic Name, Address, and Phone #: Current Medical Diagnoses i.e. asthma, diabetes, seizures, etc 4. Treatment? Previous Surgeries Approximate Date Location/Hospital Previous Hospitalizations Approximate Date Location/Hospital Medication Allergies: Food Allergies: Are Immunizations Up-to-Date? Developmental History: Pregnancy: Mother s Age During Pregnancy: How many total pregnancies for mother? Any complications during the pregnancy? ie. pre-term labor, high blood pressure, gestational diabetes Prenatal Care Began in Which Trimester? 1 st 2 nd 3 rd Which pregnancy was this one? Maternal drug, alcohol, or tobacco use during pregnancy? Labor and Delivery: 3
4 Due Date: Hospital: Vaginal or C-Section? Anesthesia? Epidural, Spinal, General, IV, None APGAR Scores? Complications During Delivery? Birth Date: City, State: Forceps or Vacuum Assisted? Length of Labor? Birth Weight? Neonatal History: Was your baby in the NICU? Did your baby have any nursery complications? Jaundice? Feeding problems? Infections? How long did your baby stay in the hospital? Did your baby require resuscitation or oxygen? Milestones: Please provide the age (in months) when your child attained the following milestone. Sit unassisted Walk independently Finger feed Use mama/dada only for parent Point to indicate needs/wants Used 50 words Hand-knee crawl Pedal a trike Toilet trained First word Used words Put two words together Family/Social History: Who lives in the child s home? Does the child have a second home where they spend part of the week? Are parents married/partnered/separated/divorced? How long have parents been married (if applicable)? Mother Name: Father Name: Step-Mother (if applicable) Step-Father (if applicable) 4
5 Name: Name: Siblings Name DOB & Age Relationship (full,1/2,step,etc) Grade Medical Problems? Psychiatric Problems? Family History: Please indicate if there is a family history of the following conditions and who is affected with the condition. Anxiety Heart disease Depression Sudden cardiac death Bipolar disorder Cancer ADHD Alcoholism Autism Drug abuse Eating Disorders Thyroid problems Learning disabilities Seizures Other psychiatric conditions? Other medical conditions? Educational History: Current School: Address: Grade: Does your child have an IEP or 504 Plan? Does your child receive Speech Therapy at school? Does your child receive Occupational Therapy at school? Has your child ever been suspended from school? County/School District: Phone Number: Type of Class: Regular, Inclusion, Self-Contained, etc? Is your child in Exceptional Student Education (ESE)? Exceptionalities: SLD, Autism, OHI, etc? Does your child receive Physical Therapy at school? Has your child ever been expelled from school? Please list the previous schools that your child has attended: 5
6 Years Grades School Name Type of Class Any problems? Suspensions, Expulsions, etc Legal History: Arrest(s): Date(s): Substance Abuse History please include age of first use and frequency if known: Alcohol Cocaine (crack, coke) Opiates (heroin, pain killers, methadone) MDMA (ecstasy) Over the Counter (cough syrup, triple C s, laxatives) Amphetamines (speed, Adderall, Ritalin) Other: Marijuana (weed) Tobacco Benzodiazepines (Xanax, Klonopin, Ativan, Valium) LSD (acid, hallucinogens) Bath Salts, Spice, K2 Inhalants (dusters, whip its) Other: Any other issues not yet addressed? Past Psychiatric Medication 6
7 Anti Depressants Amitriptyline (Elavil) Bupropion (Wellbutrin) Citalopram (Celexa) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Imipramine (Tofranil) Mitrazapine (Remeron) Nefazodone (Serzone) Nortriptyline (Pamelor) Paroxetine (Paxil) Phenelzine (Nardil) Dexvenlafaxine (Pristiq) Sertraline (Zoloft) Tranylcypromine (Parnate) Trazodone (Desyrel) Venlafaxine (Effexor) AntiAnxiety Alprazolam (Xanax) Buspirone (Buspar) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Clorazepate (Tranxene) Diazepam (Valium) Flurazepam (Dalmane) Hydroxyzine (Vistaril) Lorazepam (Ativan) Oxazepam (Serax) Temazepam (Restoril) Triazolam (Halcion) Zolpidem (Ambien) Response (Good, Fair, Poor) Antipsychotic Olanzapine (Zyprexa) Perphenazine (Trilafon) Pimozide (Orap) Quetiapine (Seroquel) Risperidone (Risperdal) Asenapine (Saphris) Thioridazine (Mellaril) Thiothixene (Navane) Trifluperazine (Stelazine) Mood Stabilizers Carbamazepine (Tegretol) Gabapentin (Neurontin) Lamotrigine (Lamictal) Lithium (Lithobid, etc) Topiramate (Topamax) Valproic Acid (Depakote, etc) ADHD Medications Amphetemine salts (Adderall, etc) Clonidine (Kapvay, Catapres) Dexmethylphenidate (Focalin) Guanfacine (Intuniv, Tenex) Methylphenidate (Ritalin, Concerta, Daytrana, etc) Strattera (Atomoxetine) Vyvanse (Lisdexamfetamine) Miscellaneous Thyroid (Synthroid, Cytomel) Dilantin (Phenytoin) Propranolol (Inderal) Naltrexone (Revia) Benztropine (Cogentin) Trihexyphenidyl (Artane) L-Dopa Response (Good, Fair, Poor) Antipsychotic Aripiprazade (Abilify) Fluphenazine (Prolixin) Haloperidol (Haldol) Lurasidone (Latuda) Other Medications 7
Early Morning Waking Excessively Orderly or Perfectionistic
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