CHILD AND ADOLESCENT EVALUATION

CHILD AND ADOLESCENT EVALUATION: Patient Form
Date:

MonthDayYear
Patient Name:*
Sex:
Patient D.O.B.:*

MonthDayYear
Provider:
Evaluation Date:

MonthDayYear
Form filled out by:
Referred by:
Persons present for evaluation:
Briefly describe the events that led up to this appointment:
What concerns you most about your child?
What are your goals for the evaluation?
Have you seen other professionals about these problems? If yes, list these contacts and approximate dates of evaluation and treatment (include hospitalization dates).
Please list past and current medications and approximate doses and dates of treatment.
Developmental History
Pregnancy / neonatal / infancy:
Were there complications with the pregnancy or your child's delivery (for instance, medications, prematurity, fetal distress, low Apgars, C-section)? Were there any medical problems in the first two years of life?
Developmental milestones and concerns:

Did/does your child have problems with the following developmental milestones?
Please note the dates you had concerns about the problem.
Feeding concerns?
Breast Feed? How long?
Physical growth problems?
Colic?
Sleep habits?
Sleep through the night?
Sleeping alone?
Age of walking?
Clumsiness?
Age of first words, first sentences?
Other language concerns?
Age of bowel training? Current soiling?
Age of bladder training? Current wetting?
Hygiene concerns?
Problems separating from parents?
Past and current peer relations?
What do you see as your child's strengths and weaknesses?
What is your child's grade and school?
What other schools has he/she attended?
Has your child been in special education? Have there been learning problems? Give details of problems and supports
Do you have concerns about the school program?
Has there been psychological testing? When? Results? Bring to the evaluation if available.
What is your child's attitude toward school?
What are your hopes for your child's educational attainment and vocational future?
List the names, ages, and occupations/grades of family members in the current household.
List immediate relatives (biological or related by marriage, parents or siblings) or other primary caretakers (sitters, day care) of the child outside the primary home. Has there been any significant history of problems with caretakers, such as abuse or neglect?
Are there any particular stresses or recent changes in the family such as job changes, financial problems, school changes, health problems, marriage or divorce, violence, or substance abuse?
Who is responsible for disciplining? What methods work or haven't worked? Do caregivers/parents agree on discipline? Is there allowance? Are there chores?
How well does your child get along...
with siblings?
with peers?
with parents?
by himself / herself?
What are family activities or mealtimes like? Does your child have other activities or hobbies? Favorite TV or movies?
Child's local physician:
address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
phone:

Area CodePhone Number
last physical exam:

MonthDayYear
Has your child seen a specialist, such as a neurologist, etc.? Please list names, approximate dates, and reasons for consultation.
Allergies (environmental, food, and/or medication related)
Current medicines, or any medicine ever taken over 6 months duration (include over the counter or "natural" medicines).
Please check any of the following medical issues that apply to your situation. Add comments if necessary:
Type a question

Asthma or breathing problemsHeart murmur or problemsHeadachesHospitalizations or surgeriesGastrointestinal concernsHearing loss (testing done?)Head injury historyVision problemsSeizuresOnset of puberty or mensesEar infectionsSexual activityFrequent or recent strep infectionOther medical concerns
Details:
Family History

Please identify if there is a history of the following problems in the child's genetic
or natural family, and indicate briefly the problem and relative (for example,
seizures in a maternal aunt).
Alcohol or drug problems in family members
Eating problems in family members
ADHD or school behavior problems in family members
Conduct problems or court involvement in family members
Mental retardation, learning, disabilities, or other developmental problems
Mood problems, including suicide, depression, or manic-depressive illness, treated or untreated in family members
Anxiety and panic problems in family members
Schizophrenia in family members
Neurologic problems such as seizures, or migraines
Tics or Tourette disorder
Thyroid problems in family members
Genetic syndromes in family members
Cardiac or other medical problems in family members
PLEASE SELECT AND COMMENT AS APPROPRIATE:

careless / poor attention to detailsfidgetsdifficulty sustaining attentionleaves seatdoesn't listenruns about / subjectively restlessdoesn't follow through with requestsdifficulty playing quietlydifficulty organizing"On the go"/ "motor driven"avoids effortful tasksexcessive talkloses necessary thingsblurts out answerseasily distracteddifficulty waiting turnforgetful in daily activitiesinterrupts/intrudes
Where are these problems present, in the home, in the school, or in other settings? Comments:
PLEASE SELECT AND COMMENT AS APPROPRIATE:

stealing in the home or out of homecruelty to animalslyinglegal involvement with juvenile servicestruancy/runawayinappropriate sexual interests and behaviorviolence in the familylack of conscienceviolence at schoolthreats of violenceviolence in the communityexceptional negativity to rulesfire setting or fireplay
Comments:
PLEASE SELECT AND COMMENT AS APPROPRIATE:

alcohol usecigarette usemarijuana useother substance use
Comments:
PLEASE SELECT AND COMMENT AS APPROPRIATE:

expresses depression or hopelessness or low self esteemcan be irritable or giddy or elated inappropriatelyhypersexual or loss of other inhibitionsmood swings (circle period of change MINUTES, HOURS, DAYS, WEEKS, or MONTHS)moods change without reasonlack of interest in friends or normal activitiespoor sleep or excessive sleeppoor eating or excessive eating or concerns over weight changes or dietingbinging with or without purging (self induced vomiting)suicidal talk or acts of self harm or mutilation
Comments:
PLEASE SELECT AND COMMENT AS APPROPRIATE:

school refusal or excessive absencesanxiety at bedtime or in the night / refusal to sleep alonefears of harm to family memberscomplaints of physical symptoms such as headache or stomach achespecific phobias (heights, spiders, etc.)sudden feelings of panicrefusal to speak in public, or refusal to go out in publichistory of trauma (abuse, accident, etc.)nail biting, thumb sucking, teeth grinding, hair pulling, skin pickingexcessive hand washing, or repetitive touching, or checking, or other "rituals"overconcern regarding germs, illnesses, contamination by dirt, or other obsessive thoughtsoverly perfectionistic
Comments:
PLEASE SELECT AND COMMENT AS APPROPRIATE:

tics or twitches of the mouth, eyes, facial muscles, or arms and legshead banging or rockingother repetitive behaviors causing self injury (biting, scratching, etc.)other repetitive movements such as jumping or arm/hand flapping or spinninglack of affection (doesn't seek out or provide comfort)little need for reassurance in a strange situation, or little stranger anxietypoor peer relations/ no real friendsproblems understanding feelings of others during interactionsdistress over changes in routineunusual toy or play interests (collections, string, line up or take apart toys rather than play)restricted conversational interests (dinosaurs or specific topics to the exclusion of other topics)hoarding food or other objects
Comments:
PLEASE SELECT AND COMMENT AS APPROPRIATE:

odd thinking or peculiar ideasdifficulty discerning what is real vs. normal fantasy playparanoid thinkinghearing voicesseeing things not thereperiods of odd sensations or loss of memory for a period of time
Comments:
PLEASE ALSO COMMENT BELOW IF YOU HAVE OTHER CONCERNS NOT RAISED IN THE PREVIOUS SEVERAL PAGES:
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CHILD AND ADOLESCENT EVALUATION: Patient Form