Child and Adolescent Developmental Questionnaire



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Child and Adolescent Developmental Questionnaire Child s Name:. Age Date of Birth Person completing this form: Relationship: Sex: M / F Date: Current Problems What is the # 1 concern causing you to seek help now? When did the problem seem to begin? What other changes have you noticed in your child since this problem began? _ What was the recent last straw that caused you to call and make an appointment now? What are you hoping I can do to help you and your family? What things have you tried to deal with the problem? _ Did you see other professionals for help with this problem? If so, what sort of things did you like / not like about the care they provided? Environmental and Family Issues Please list all the people living in the house with you and your child: Name Age Relationship This child has how many total: older siblings older half-siblings younger siblings younger half-siblings Is this child adopted? Y / N If yes, please describe the circumstances of the adoption. Randall V. Sellers, MD Child & Adolescent Developmental Questionnaire Page 1 of 8

Marital Status of Biologic Parents Biologic Father: Married, to, from to Married, to, from to Biologic Mother: Married, to, from to Married, to, from to If Biologic Parents are divorced, who is the Managing Conservator? Joint Mom Dad How often does the child visit with the other parent? Child Care If your child attends any child care/day care please list the following: Name how long they have attended Discipline What kinds of things do you do to discipline your child (please give examples): Who does most of the disciplining in the house? Is their disagreement about discipline? If so, please explain Current Treatment Please list the name and phone number of any therapist / counselor your child is currently seeing: Please provide the following for ANY medications (of any kind), vitamins, supplements, your child is currently taking: Name dose when started Dr. s Name Hobbies / Interests / Friends What Teams, clubs, extra curricular activities, or jobs is your child involved in? What things does your child do to occupy him/herself around the house? Who does your child spend time with? Randall V. Sellers, MD Child & Adolescent Developmental Questionnaire Page 2 of 8

Educational History School: Phone #: Teacher: Grade: May I have permission to contact your child s teacher? Y / N If yes, Signature: Date: Is homework a problem for your child? Y / N If yes, in what way? Is your child receiving any special services? Y / N. For what difficulties? When was the last ARD? (please bring a copy of the last ARD and any evaluations that have been done) List previous schools, dates attended, and overall performance: Grade School Date Performance Was your child in any special programs in the past? Y / N. What kind of program? When did he/she leave the special program? Please list your child s best subject: worst subject: Grades repeated: Grades skipped: If your child has ever been suspended or expelled, please tell me about that: Legal Is your child involved in a lawsuit? Y / N If yes, is mental health a factor in the case? Y / N Have the police ever been called to your home? Y / N If yes, when and for what reason? Has your child ever been arrested? Y / N If yes, for what reason? If your child has a probation officer, please list name and phone number: Has your child ever been involved with CPS (Child Protective Services) or DHS (Department of Human Services)? Y / N If yes, when and for what reason? Has there ever been a time when you thought your child was being abused? Y / N If yes, please explain:. Randall V. Sellers, MD Child & Adolescent Developmental Questionnaire Page 3 of 8

Mental health History Please list any mental health professional (Psychiatrist, Psychologist, Counselor you have seen for your child/teen in the past Professional s Name From.. to. Problem or Concern Please list any psychiatric hospital, residential treatment center, group home, day hospital, foster home, or half way house: Name From to.. Problem or Concern The following area asks about previous psychiatric medications. If your child has not taken any psychiatric medications,, continue to the next page. If your child has taken medications in the past, the following is very important. Please try to recall any and all medications for it will be very important in deciding the best care in the future. Drug Name Dr. s Name Start / Stop Problem Side Effects Randall V. Sellers, MD Child & Adolescent Developmental Questionnaire Page 4 of 8

Developmental and Medical History Pregnancy and Delivery Did any of the following conditions occur during pregnancy or delivery? Bleeding No / Gain > 30 pounds Toxemia / pre-eclampsia Rh Factor incompatibility Frequent nausea or vomiting Serious illness or injury Took prescription medication ; if yes, name Took illegal drugs Used alcoholic beverages ; if yes, # drinks/week Smoked cigarettes ; if yes, # cigarettes/day Medication to ease delivery pain ; if yes, name Delivery was induced No /Yes Forceps used during delivery Breech delivery C-Section (Caesarean Delivery) Other problems ; if yes, describe Did any of the following conditions affect your child during delivery or within the first few days after birth? Injured during delivery Heart/breathing distress during delivery Delivered with cord around neck Had trouble breathing after delivery Needed oxygen Was cyanotic, turned blue Was jaundiced, turned yellow Had an infections Had seizures Was given medications Born with a congenital defect Was in hospital > 7days Infant Health and Temperament During the first 12 months, was your child: Difficult to feed Difficult to get to sleep Colicky Difficult to put on a schedule Alert Cheerful Affectionate Sociable Easy to comfort Difficult to keep busy Overactive, in constant motion Very stubborn, challenging Early Developmental Milestones Sitting without help Normal / Fast / Slow / Don t Know Crawling Normal / Fast / Slow / Don t Know Walking alone, without aid Normal / Fast / Slow / Don t Know Using single words (mama, dada) Normal / Fast / Slow / Don t Know Putting 2 or more words together (mama up) Norm / Fast / Slow / DK Bowel training, day and night Normal / Slow / not yet Bladder training, day and night Normal / Slow / not yet Randall V. Sellers, MD Child & Adolescent Developmental Questionnaire Page 5 of 8

Health History Name of Child s Physician: Date of last physical exam: ; last visit: Is it all right for me to contact him / her? Yes / No At any time, has your child had the following? Never Past Now Surgery Hospitalization Appetite problems Weight loss or gain Fever or chills Eye or vision problems Chronic ear infections Speech or language problems Hearing problems Snoring Diarrhea or constipation Asthma Heart murmur High blood pressure Irregular heart beat Chest pain with exercise Fainting while exercising Rashes Birthmarks Hair loss Excessive sweating Sleep problems Nightmares Sleepwalking or talking Head banging Wetting problems Lead poisoning Anemia Arthritis Broken bones Severe cuts requiring stitches Epilepsy or seizure disorder Meningitis / brain infection Head injury with loss of consciousness Clumsiness Intolerant of cold or heat Diabetes Airborne Allergies Alcohol use Drug abuse Cigarette Smoking Medication Allergies Randall V. Sellers, MD Child & Adolescent Developmental Questionnaire Page 6 of 8

Family History Many times, medical and emotional problems run in the family. Knowing this can make a difference in what treatment I may recommend for your child. The family includes: Mom, Dad, brothers, sisters, Aunts, Uncles, and Grandparents This is a list of some problems that run in the family. Please circle any in the family. ADD/ADHD Depression / Bipolar Child Abuse Diabetes / Thyroid disease Repeating grades Suicide Attempts Incest Heart Disease Mental Retardation Nervous Breakdown Eating Disorder Death < 50 y/o Arrests / Prison Alcohol / Drug Abuse Obsessive Compulsive Not Graduate High School Schizophrenia Too much Worry Please complete the following for your child s family. This will assist me in developing a genogram or family tree Biologic Father s Family Biologic Father His Father His Mother First Name age (if deceased, please give age and year of death) Biologic Mother s Family Biologic Mother Her Father Her Mother First Name age Patient s Brothers and Sisters First Name age If your child was adopted, please list at what age and any information you may know about his / her biologic family. Randall V. Sellers, MD Child & Adolescent Developmental Questionnaire Page 7 of 8

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