PARENTAL QUESTIONNAIRE (Children & Adolescents)
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- Ambrose Mosley
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1 Marquette General Health System Marquette, Michigan PARENTAL QUESTIONNAIRE (Children & Adolescents) The information requested on this form serves two purposes. It allows us to learn many things about you and your background in a way that we can more clearly understand the reasons you have for coming in. It also allows us to gather information we are required to have by our accrediting organization, but may or may not be important to you. While we recognize that this will take time to complete, it ultimately saves you time with your clinician, so that you can pay more attention to the concerns that bring you in. Thank you for your cooperation and participation. Name of Person Completing Form: Today s Date: Child s Name: Birth Date: Age: Race: Sex: Child s School: Grade: Teacher s Name: If parents are not married, who has legal custody of child? Adult(s) child is presently living with: (siblings should be listed on next page) Biological Mother Biological Father Step Mother Step Father Adoptive Mother Adoptive Father Foster Mother Foster Father Grandparents Other (specify) Non-residential adults involved with this child on a regular basis: Who referred you to our services? Name/Address/Phone: Briefly state your main concerns with this child: Are you aware of, or do you suspect any drug use, consumption of alcohol, or inhalation of chemicals? Yes No Previous Behavioral Health Treatment: Please indicate any previous treatment you have received for mental health or substance abuse problems: Approximate Dates Type of Treatment Institution/Provider Problem for which you sought help How helpful was your care? C:BHSFORMS\BHS#006B Parental Questionnaire
2 Page 2 of 6 PARENTS Mother s Name: Age: Age at time of pregnancy: Mother s Occupation: Business Phone: Past Current Learning Problems Attention Problems Behavior Problems Drug or Alcohol Problems Emotional/mental Problems Medical Problems Father s Name: Father s Occupation: Age: Business Phone: Past Current Learning Problems Attention Problems Behavior Problems Drug or Alcohol Problems Emotional/mental Problems Medical Problems Have any other blood relatives (grandparents, uncles, aunts, etc.) had any of the following problems? Past Current Learning Problems Attention Problems Behavior Problems Drug or Alcohol Problems Emotional/mental Problems Medical Problems CHILD S SIBLINGS Name Age Medical, Social, or School Problems
3 Page 3 of 6 PREGNANCY Complications Excessive vomiting Excessive staining/blood loss Hospitalization or bed rest required Threatened miscarriage Toxemia Smoking during pregnancy # of cigarettes per day Infection(s) (specify) Operation(s) (specify) Other illness(es) (specify) Describe alcohol consumption during pregnancy (amount, frequency) Medication taken during pregnancy Other drugs used during pregnancy Duration of pregnancy (check one) Early Normal Late DELIVERY Type of Labor: Spontaneous Induced Duration (hrs.) Type of Delivery: Normal Breech Caesarean POST DELIVERY PERIOD Jaundice Cyanosed (turned blue) Incubator Care Infection (specify) Number of days infant was in hospital after deliver Birth weight BEHAVIORAL PATTERNS: (Please check any of the following that have either been a problem in the past or are a problem currently) Clingy Irritable Mood swings Refusing to eat Inducing vomiting Hoarding food Over eating Overly active Under active Afraid of others Shy Easily frustrated Tantrums Aggressive behavior Cruel to animals Fire setting Defiant Unorganized Distractible Indecisive Stealing Lying or storytelling Wets or soils clothes Poor concentration Suicidal thinking Past Current Past Current Difficulty with changes in routine Crying Sexual behaviors Bossy Fighting Destructive to property Accident prone Odd noises Motor or Vocal Tics Negative attitude Odd behaviors Chewing on things Thumb sucking Morning problems Evening problems Difficulty going to sleep Restless sleeping Nightmares/Night terrors Snoring Sleep walking Sleep talking Bed wetting Impulsivity Self-injurious behavior
4 Page 4 of 6 SCHOOL Does your child have difficulty paying attention in class? Are there problems with your child s grades? Has your child ever been recommended for special services? Has there ever been a request from the school for mental health or chemical dependency services? Has your child ever repeated a grade? Does your child have behavior problems in the classroom? Does your child have a good relationship with the teacher? Does your child have friends at school? Does your child complain of health problems to stay home? Is your child afraid of going to school? Does your child skip school? Describe any specific learning problems or learning disabilities identified in your child: Yes No MEDICAL HISTORY Name of child s doctor Date last treated and reason for treatment Date of last complete physical Any abnormal results? Any physical disabilities or limitations? No Yes If yes, please explain Is your child up to date on his/her immunizations? No Yes When did your child speak his/her first words and sentences, sit up, crawl, walk & complete potty training? Child s Height Child s Weight Present illnesses for which the child is being treated: Has your child received (or receiving) occupational therapy, physical therapy and/or speech therapy? If so, when and who provided it:
5 Page 5 of 6 Please check if any of the following have been a problem in the past or are currently a problem: Acne Allergies Asthma Birth Defect Bladder Trouble Cancer Frequent Chest Colds Constipation Coordination Problems Frequent Coughing Dental Problems Diabetes Diarrhea Dizziness Frequent Ear Infections Epilepsy Fainting Growth Problems Head Injury Frequent Headaches Hearing Problems Heart Problems Hypoglycemia Kidney Disease Lead Poisoning Muscle Aches/Cramps Nose Bleeds Rashes/Hives Rheumatic Fever Seizures Sinus Problems Frequent Sore Throats Speech Problems Stomach Problems Strep Throat Thyroid Illness Vision Problems Vomiting Headaches Persistent Physical Pain Other MISCELLANEOUS Please briefly describe your child s and family s religious involvement: Please describe your child s ethnic and cultural background: Please describe your child s interests and leisure activities: Please tell us what your child does well and what things you enjoy about your child: Please describe any legal problems your child has experienced and what these were and when they occurred. Include the name of the probation officer if applicable. Does your child have a history of: Physical abuse: Yes No Sexual Abuse: Yes No
6 Page 6 of 6 Any adverse/allergic reactions to medications? Yes No. If yes, please explain: Significant Surgeries, hospitalizations, or other medical procedures: (include the month/year that these occurred) Medical diagnoses and conditions: (heart disease, cancer, diabetes, etc ) Please provide the name and dosage of prescription medications your child currently uses (write on back of this page if additional space is needed. Medications child is taking on an on-going basis: Dosage: Prescribing Physician: Please provide the names of all over-the-counter, herbals, and/or supplements that your child currently uses: Completed by: Reviewed by: Signature Date Clinician Signature Date THIS SECTION FOR OFFICE USE ONLY Physical Examination Recommended: Yes No Parent/guardian Response to Recommendation: Yes No C:BHSFORMS\BHS#006B Parental Questionnaire
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