CHILD PSYCHIATRIC QUESTIONNAIRE



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CHILD PSYCHIATRIC QUESTIONNAIRE Developed by Thomas W. McCormack, M.D. Dear Patients/ Parents/ Caretakers: Please carefully fill in this form prior to your first appointment in order to help us reduce the time and cost of gathering this information at our office. We appreciate your cooperation and patience. Patient s Name: Date of Birth: / / Patient s Birthplace: Sex: M F Race: African-American Caucasian Latino Asian Other Person completing this form: Relation to child: Who referred you for an evaluation? Please briefly describe the problems for which you are seeking help at this time. Approximately when did the problem(s) begin? Any known stress cause or contribute to the problem(s)? No Yes If Yes, please describe stress: 1

Has the patient ever received outpatient mental health treatment? No If yes, please list in order, including Psychological or IQ/School testing: Clinician/ Doctor Date(s) of Evaluation or Treatment Type of Evaluation or Treatment Frequency of visits Has the patient ever received inpatient mental health treatment? No If yes, please list in order: Hospital Name Dates of Treatment Reason for hospitalization If your child has ever taken psychiatric medications, please list them below: Not applicable Rx Name Reason Given Highest Dose % Improvement Side-effects Dates Taken Has your child ever threatened or attempted suicide? No If yes, please describe: Has your child ever had any brain imaging or functional studies? (MRI, CAT scan, EEG, etc.) No 2

Family Psychiatric History: (Please note ADHD, Learning Disorders, Depression, Bipolar Disorder, Anxiety Disorders, Obsessive-Compulsive Disorder, Tic/ Tourette s, Schizophrenia, Drug or Alcohol Abuse, Suicide attempts, or other Psychiatric Problems). Is there a history of ADHD, mental illness, mental retardation, learning problems, alcohol or drug abuse in the patient s grandparents, parents, siblings, or 1 st cousins? No If Yes, please fill in the following chart: Affected Family Member Type of Mental Illness or SA Treatment (if any) Childhood Development: Pregnancy---Please check any that apply to the mother s pregnancy with this child: Describe Received prenatal care Drank alcohol during pregnancy Smoked during pregnancy Used drugs during pregnancy Took medications Infection(s) Nausea or Vomiting Severe Emotional Distress Elevated blood pressure Diabetes of pregnancy Pre-eclampsia Premature labor Threatened miscarriage Birth History: Mother s age at time of birth: years old. Father s age at time of birth: years old. Was mother given medication or anesthesia? Don t know No Delivery was: Spontaneous Vaginal Induced Caesarian section Any complications with labor or delivery?.. No Was the baby premature?. No Baby s birthweight: lbs oz Did baby have any of the following: Breathing problems. No Cord around the neck... No Abnormal color No Abnormal tone.. No Meconium.... No Failure to thrive No Jaundice No Infection. No 3

Developmental Milestones (answer as best you can recall) Motor Development (sitting, crawling, walking). Normal Fast Slow Speech & Language. Normal Fast Slow Self-help skills (dressing, brushing, toileting, hygiene). Normal Fast Slow Temperament as Infant: Easy baby Slow to Warm up Difficult/ Colicky Medical History: Who is your child s Pediatrician or Family Doctor? When was your child s last physical examination? Current Medications (include Over-the-counter meds, Vitamins, Herbs, or Supplements) None OR Please List: Rx Name Dosage Frequency Prescribing M.D. Does your child have any drug allergies? No (please list): Does your child have any current medical problems? No (please list): Please check & briefly describe if your child has experienced any of the following conditions: Surgeries Chest pain Abnormal heart rate or rhythm High Blood Pressure Seizures/Convulsions Staring spells Head injury Frequent Strep Throat infections Frequent Headaches Frequent Stomach Aches Vision problems Hearing problems Significant accidents or injuries Bedwetting Fecal soiling of clothes Exposure to Lead or Mercury 4

Social History: City of Residence: Now Living with: Both Bio parents Bio Father Bio Mother Other: Other Children in family: Names & Ages: Is the child adopted?. No 5 If Yes, Please describe the circumstances of the adoption : Has the patient ever experienced or witnessed any physical abuse, sexual abuse, or neglect? No If Yes, please briefly describe: Hobbies/ Interests: Any concerns about peer relationships/ social skills? School History: Name of School: Grade: Current Academic Performance:. Good Fair Poor Past Academic Performance:... Good Fair Poor Current Behavioral Performance: Good Fair Poor Past Behavioral Performance:. Good Fair Poor Grades Repeated: Is child in any special education programs?.... No (explain): Any known Learning Disabilities?. No (explain): Legal Problems: Has your child has ever been arrested or had legal charges?.. No (explain): Substance Use: Do you suspect that your child has ever used tobacco, alcohol, or drugs? No (explain): Religious Beliefs: None Jewish Muslim Hindu Christian (denomination) Other

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