Frequency of stool times per day / times per week

What does the stool look like?   Please describe   

Does your child have pain on passing stool?   Yes   No     
    
Have you noticed any abnormalities in your child's stools? (colour changes, consistency, undigested foods)   Please describe   

Does your child experience any urinary symptoms?   Please describe   

Does your child have trouble falling asleep?   Yes   No   

If your child has nightmares, what is the theme:   Please describe   

What position does your child sleep in? :Please describe

Who takes care of the child primarily?    
Does the child have a babysitter/nanny?   Yes   No      
Does the child go to daycare?   Yes   No      
What are the family's favourite activities?   
Does your child get along well with other children?   Yes   No  
Does your child get along with adults?   Yes   No     
What does your child do with unstructured time?   Type a label    
What extra activities is your child involved in?   Type a label    
How does your child keep his/her room?   Type a label    
Describe your child's temperament.   Type a label    
Does she/he prefer to play alone or with others?   Type a label    

What makes your child angry?      
Does your child get angry often/easily?      
Does your child experience uncontrollable rage?      
Does your child have difficulty expressing anger?     

What makes your child sad?      
Does your child cry when sad?      
Does your child cry often/easily?     

List major experiences of grief/loss in your child's life:  
          

What fears does your child have?