HEALTH AND DEVELOPMENT HISTORY Date and time:

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PAEDIATRIC PSYCHIATRY HEALTH AND DEVELOPMENT HISTORY Date and time: LIVING/SOCIAL ENVIRONMENT: Who lives at home with your child? Are the child s parents separated? NO YES, Describe (date of separation) Are the child s parents divorced? NO YES, Describe (date of divorce) Are there current custody proceedings? NO YES, Describe Mediator/OCL/Attorney: Telephone: Is the child in Foster placement? NO YES, Describe Is the child adopted? NO YES, Describe (The age of the adoption? Is the child aware? At what age was your child informed?) Does your child have any parent(s) who live outside of the home? NO YES If yes, indicate the frequency of visits: Is the child in CAS custody? NO YES If YES,CAS case manager s name and phone number: 1

DEVELOPMENTAL HISTORY: Was this a planned pregnancy? : NO YES During pregnancy: Please circle yes or no to the following questions about your pregnancy Diabetes? Toxemia? Any medications taken? Excessive vomiting? Excessive blood loss? Drug use? Hypertension? Threatened miscarriage? Alcohol use? Maternal depression? Pre-term labor? Did you smoke? Infection? Hospitalization? Were X-rays taken? Labor/Delivery: Gestational age Forceps Delivery APGAR Scores: rmal Vaginal Delivery Cord around the neck Incubator Care Induced Vaginal Delivery Birth Injury C-Section Newborn: Medical problems: NO YES Low birth weight Heart Problems Seizures Apnea Sepsis Drug withdrawal Jaundice Feeding problems ICU stay Infancy: Temperament Enjoyed Cuddling YES NO More active than others YES NO Colic/Fussy, Irritable YES NO Soothing Difficulties YES NO Feeding Difficulties YES NO Sleeping Difficulties YES NO 2

MILESTONES: If you can recall, record the age at which your child reached the following developmental milestones. If you cannot recall, check the appropriate box at the right on the chart below: Sat without support Crawled Stood without support Walked without assistance Threw ball Spoke first words Said phrases Said sentences Bowel trained Bladder trained, day Bladder trained, night Rode tricycle Rode bicycle Separated from mother (day care or school) Age Early On time Late As an infant, toddler, and preschooler did your child have any. Unusual behaviors: Hand flapping Head banging Spinning/Self stimulation Body rocking Self biting Toe walking Or Unusual interests: Traffic lights Arranging toys in rows Interest in toy parts, such as car wheels Fascination with spinning objects Attachment to unusual objects, (sticks, stones, strings, or hair) 3

MEDICAL HISTORY: please check the appropriate column NO YES Details/Current Medications: EAR INFECTIONS EAR TUBES PLACEMENT VISION PROBLEMS HEADACHES SEIZURES HEAD INJURIES ASTHMA HEART PROBLEMS DIABETES HIGH CHOLESTEROL ELEVATED LEAD LEVEL STOMACHACHES IMMUNIZATIONS - UP TO DATE? ALLERGIES PAST SURGERIES Pediatrician s name and phone number 4

PSYCHIATRIC HISTORY: 1. Has your child received previous outpatient psychiatric counseling? If yes, please describe below: NAME OF PROVIDER NAME OF THE AGENCY START & END DATES 2. Has your child ever been hospitalized for psychiatric treatment? : If yes, please describe below NAME OF THE HOSPITAL START & END DATES REASON 3. Has your child ever taken medications for emotional/behavioral disorders? If, please list the all medications your child has ever been on, starting with the current (Include herbals and over the counter medications): MEDICATION DOSE FREQUENCY START/END DATE SIDE EFFECTS 5

Does the child have a history of : Emotional abuse Neglect Witnessing Violence Physical abuse Sexual abuse Perpetrator(s): Relationship to Child: Victim(s): Relationship to Child: Report Filed NO YES, When: CAS Involved: NO YES Caseworker Phone number: Pending Court Appearance: NO YES, Date: Orders of Protection: NO YES Has the child ever been arrested NO YES, if yes, please explain: Has the child ever been on probation? NO YES, Probation Officer Telephone: Has the child ever had a court appearance: NO YES, Description/Outcome: Probation/Parole NO YES, Probation Officer: Telephone: ACADEMIC HISTORY: SCHOOL CONSENT Name of school Grade Phone number Has your child ever been held back in school? NO YES If, please explain: Have teachers or others told you that your child has a learning disability? NO YES If, please explain: Has your child ever had educational or cognitive psychological testing? NO YES If, please explain(dates and results) Has your child ever had any of the following services? Special Education NO YES IEP NO YES TA or aid or 1:1 NO YES Mainstreamed with services NO YES Resource Room NO YES Home Schooling/Tutoring NO YES 6

FAMILY HISTORY: Have any of your child s family members ever been diagnosed by the following mental health problems? If yes, please explain: Depression: Manic Depression (Bipolar): Anxiety: Schizophrenia: Attention Deficit/Hyperactivity: AlcoholUse: Cocaine//heroine use: Mental Retardation: Learning Disability: Suicidal behavior: Homicidal behavior: Nervous breakdown : Anger problems : Nervous wreck : Dr. Andrej Brajović, M.D. Adult and Paediatric Psychiatry Joseph Brant Community Health Centre Telephone 905-631-1939 or Fax. 905-631-0513 7

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