Child Information FormPatient Name*Date of Birth*Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Driver License No. AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Educational StatusFull Time StudentPart Time StudentN/AIf student, permanent/parents addressName of SchoolEmployers NamePhoneReferring physicianPhoneResponsible PartyPhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code D.O.B.Present Problems1) Describe as specifically as possible the problems which have led you to seek treatment or evaluation for your child.2) What do you believe to be the most important factors causing these problems?3) At what age did you first notice these problems?4) Have there been any family changes or difficulties (new baby, family arguments, divorce) which may be related to these problems?5) Has your child ever been treated for any behavioral and /or emotional problems?YesNo6) Has your child experienced any of the following?Makes up stories excessivelyYesNoAgeHow Often?Talks to imaginary companionsYesNoAgeHow Often?Sees or hears things that do not existYesNoAgeHow Often?Runs away or sneaks outYesNoAgeHow Often?Sets firesYesNoAgeHow Often?Had problems with the lawYesNoAgeHow Often?Talked about or threatened to harm selfYesNoAgeHow Often?Has harmed selfYesNoAgeHow Often?Has excessive fearsYesNoAgeHow Often?Is hyperactiveYesNoAgeHow Often?Substance abuseYesNoAgeHow Often?Sadness or depressionYesNoAgeHow Often?Aggression towards othersYesNoAgeHow Often?Temper tantrumsYesNoAgeHow Often?OveranxiousYesNoAgeHow Often?Sleeping problemsYesNoAgeHow Often?Bad dreamsYesNoAgeHow Often?Lost interest in activitiesYesNoAgeHow Often?Impulsive acts without thinkingYesNoAgeHow Often?Sudden behavior or personality changeYesNoAgeHow Often?Inappropriate sexual behaviorYesNoAgeHow Often?Poor appetiteYesNoAgeHow Often?Problems with authorityYesNoAgeHow Often?Takes risksYesNoAgeHow Often?Bad companionsYesNoAgeHow Often?Destruction of propertyYesNoAgeHow Often?7) Has your child previously been evaluated with psychological tests, e.g. intelligence testing and/or personality evaluation?YesNoIf so, please provide details:School Information1) What schools has your child attended?Name of SchoolCity/StateGradeSpecial Education2) Has your child ever repeated a grade?YesNoGrade RepeatedReasonGrade RepeatedReason3) Estimate grade average for each year of school:K12345678910114) Has your child experienced any of the following problems in school?Getting along with other childrenYesNoGradeHow Often?Short attention spanYesNoGradeHow Often?OveractiveYesNoGradeHow Often?ReadingYesNoGradeHow Often?Writing letters or numbersYesNoGradeHow Often?SpellingYesNoGradeHow Often?Finishing work in classYesNoGradeHow Often?HomeworkYesNoGradeHow Often?Frequent absences due to illnessYesNoGradeHow Often?Skipping schoolYesNoGradeHow often?Suspension from schoolYesNoGradeHow often?Behavior/conduct problemsYesNoGradeHow often?OtherYesNoGradeHow often?6) Please rate your child’s effort in school:Above AverageHighAverageLow7) What are your child’s usual conduct grades?K-23-56-89-128) Please estimate your child’s intelligence level:Above AverageAverageBelow AverageMedical HistoryName of child’s pediatrician or family doctor:Phone1 ) Does your child have any physical or medical problems or handicaps? (e.g., diabetes, asthma, heart condition)YesNoIf yes, please explain2) Is your child taking any medications?YesNoIf yes, please list below3) Does your child have any allergies?YesNoIf yes, please list below4) Has your child experienced any of the following?Soiling or lack of bowel controlYesNoDate Date Format: MM slash DD slash YYYY Wetting or lack of bladder controlYesNoDate Date Format: MM slash DD slash YYYY Any urinary infectionsYesNoDate Date Format: MM slash DD slash YYYY ConvulsionsYesNoDate Date Format: MM slash DD slash YYYY Loss of consciousnessYesNoDate Date Format: MM slash DD slash YYYY Eye examination (give date)YesNoDate Date Format: MM slash DD slash YYYY Ear examination (give date)YesNoDate Date Format: MM slash DD slash YYYY Corrected visionYesNoDate Date Format: MM slash DD slash YYYY Corrected hearingYesNoDate Date Format: MM slash DD slash YYYY Persistent headaches requiring treatmentYesNoDate Date Format: MM slash DD slash YYYY Abnormal weight loss or gainYesNoDate Date Format: MM slash DD slash YYYY Frequent colds/respiratory conditionsYesNoDate Date Format: MM slash DD slash YYYY Any known heart conditionYesNoDate Date Format: MM slash DD slash YYYY Unusual muscular weaknessYesNoDate Date Format: MM slash DD slash YYYY Rocking, head bangingYesNoDate Date Format: MM slash DD slash YYYY ThumbsuckingYesNoDate Date Format: MM slash DD slash YYYY Preoccupation with physical complaintsYesNoDate Date Format: MM slash DD slash YYYY If there were any difficulties, please explain:5) Which childhood illnesses or diseases has your child had and at what age?6) Has your child been injured in any falls or accidents?YesNoIf yes, please explain:Developmental Information:1) Were there any physical or emotional difficulties during pregnancy with this child?YesNoIf yes, please explain:2) Was this child born premature?YesNoIf yes, number of weeks early?3) Were there any of the following complaints? Long labor Forceps delivery Breech birth Eclampsia Caesarian Section OtherIf other, please explain:Did mother take any medications during pregnancy?YesNoIf yes, please list:4) Were there any immediate complications following delivery?YesNoIf yes, please explain:5) Average delays in:WalkedYesNoTalked (words)YesNoTalked (sentences)YesNoToilet trainedYesNoWeanedYesNoBegan to menstruateYesNoDeveloped secondary sex characteristicsYesNoPersonal Information:1) What are your child’s interests, strengths and assets?2) What does your child spend most of his/her free time doing?Nutritional Information:1) Has your child had an eating problem?YesNoIf yes, please explain:2) Has your child been on a special diet?YesNoIf yes, please explain:Family History1) Does the child live with both parents?YesNoIf no, who does the child live with?2) Name of mother:Age3) Name of father:Age4) Are there any of the following: Step ParentsYesNoIf yes please list names and relationship to child:Adoptive parents:YesNoIf yes please list names and relationship to child:Legal Guardians:YesNoIf yes please list names and relationship to child:5) Please list all natural and half siblings, their sex and age:6) Who else lives in the home with the child (e.g., stepsiblings, grandparents, other relatives, etc.)7) Has your child ever lived with anyone else for any period?YesNoIf yes, please explain:When:With whom:Why:8) Have any other children in the family had problems?YesNoIf yes, please explain:9) Has anyone in the immediate family (mother, father, grandparents, aunts/uncles, siblings, etc.) ever had any of the following problems?EpilepsyYesNoRelationship to childDiabetesYesNoRelationship to childMental Illness requiring hospitalizationYesNoRelationship to childNervous breakdownYesNoRelationship to childOutpatient treatment for emotional problemsYesNoRelationship to childAllergiesYesNoRelationship to childExcessive use of alcoholYesNoRelationship to childExcessive use of drugs or medicationYesNoRelationship to childSuicideYesNoRelationship to childSerious legal difficulties (prison sentence)YesNoRelationship to child10) Is there anything else you feel we need to know about your child or the family in order to provide help to him/her?(I, We) understand that this information will be used in the evaluation of (my, our) child and will be included in the child’s record. Our commitment to your privacy:Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding your child and the treatment and services we provide to him/her. We are required by law to maintain the confidentiality of health information that identifies you and your child. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your child’s PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.Signature of Parent or Legal Guardian*Date* Date Format: MM slash DD slash YYYY Signature of Parent or Legal Guardian*Date* Date Format: MM slash DD slash YYYY CLICK HERE TO PRINT THIS FORM BEFORE SUBMITTING