Penfield Psychiatry
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ADHD Testing
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Rochester, New York
Albany, New York
Flushing, New York
Montclair, New Jersey
Mental Health Assistant
Child's Name
*
First
Last
Child's Date of Birth
*
MM slash DD slash YYYY
Referred by
Reason Seeking Evaluation
*
Family Information
Mother's Name
*
First
Last
Mother's Age
*
Please enter a number from
18
to
99
.
Mother Lives With Child?
Yes
No
Mother's Marital Status
*
Married
Single
Divorced
Widowed
Mother's Marital History
Mother's Employment
Father's Name
*
First
Last
Father's Age
*
Please enter a number from
18
to
99
.
Father Lives With Child?
Yes
No
Father's Marital Status
*
Married
Single
Divorced
Widowed
Father's Marital History
Father's Employment
Others In Household
Please list names, ages and relationship to patient. One per line.
Medical Information
Child's Pediatrician
Is the child on meds?
*
Yes
No
Current Medical Problems/Medications
Allergies
Is the child in counseling?
*
Yes
No
Current counselor
Previous counselor
How often?
Is the child on psychotropic medication?
*
Yes
No
Name, Dosage and Duration
*
Previous medication name/dosage/duration
*
Has the child ever been hospitalized
Yes
No
When / Where / How Long?
*
Recent Stressors
Duration of Problem
How it Affects child
How it Affects Family
How it Affects School Work
How it Affects Friendships
What Makes It Better?
What Makes It Worse?
How long?
Problems now / in the past - please describe:
Excessive worries
Sleep
Appetite
Hyperactivity
Compulsive Behaviors
Drug/Alcohol Abuse
Excessive Crying
Hallucinations (Hearing/Seeing Things)
Unusual or Strange Thoughts
Temper Tantrums
Fighting
Excessive lying or stealing
Extreme mood changes
Suicidal Thoughts / Actions
Previous medication name/dosage/duration
Any history of seizures / head trauma / neurologic problems / lead exposure / heart problems / lung problems / endocrine problems ?
Is there anyone in the child's biological family that has had depression, attention deficit disorder, obsessive compulsive disorder, bipolar disorder, learning disability, schizophrenia, or any other psychological disorder?
Does anyone in the child's family have a substance abuse problem? If yes, please describe:
Were there any complications in the pregnancy, delivery or early medical problems? If yes, describe:
Did the child have any early difficulties with feeding, sleeping, colic? If yes describe;
Child's Primary Caretaker
*
Did the child have any delays in motor or speech development? If yes, describe:
Child's age at toilet training
How long did it take?
Was it easy or difficult?
Did the child attend preschool? If yes, were there any problems with the separation from parents, aggression toward other children or any concerns at that time?
Was the child ever the victim of physical, sexual or verbal abuse? If yes, describe:
Was the child ever involved with Child Protective Services? If yes, describe:
Did the child ever witness domestic violence? If yes, describe:
School Child Attends
Grade
Is the child receiving special education services?
Does the child have any friends?
Yes
No
How would you describe your child's ability to get along with other children:
Is the child invited to birthday parties, sleepovers, etc.?
Child's relationship with other adults:
Does the child have hobbies, participate in sports, school clubs, scouts, etc.?
Child's best qualities:
What would you most like to be different for your child?
Electronic Conscent
*
I Agree
By checking the "I Accept" box, you are signing this agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this agreement. By selecting "I Accept" you consent to be legally bound by this agreement's terms and conditions.
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