Penfield Psychiatry
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Rochester, New York
Albany, New York
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Montclair, New Jersey
Mental Health Assistant
Psychological/Neuropsychrological Testing Services Pediatric History
Patient's full Name
*
Date
MM slash DD slash YYYY
Age
*
Please enter a number from
1
to
99
.
Birth Date
*
MM slash DD slash YYYY
Sex
Male
Female
Other
Grade
*
Ethnic/Racial Background
*
Primary Language
Secondary Language
Hand used for writing
Right
Left
Current problem areas / areas of concern
Early History
Adopted?
Yes
No
Duration of Pregnancy (in number of weeks)
Please enter a number from
1
to
60
.
Complications
excessive vomiting
threatened miscarriage
excessive staining/blood loss
hospitalizations
accidents or injuries
toxemia
illnesses (specify below)
Illnesses
Smoking during pregnancy
No
Yes
Number of cigarettes per day
Please enter a number from
1
to
999
.
Alcohol use during pregnancy
No
Yes
Drinks per week:
Please enter a number from
1
to
9999
.
Medications/drugs during pregnancy
Type of Delivery
Vaginal
Cesarean
Reason why
Was labor
Spontaneous
Induced
Length of labor
Complications
none
breech
forceps
Intraventricular Hemorrhage (IVH)
retinopathy
BPD/lungs
PDA/cardiac
cord around neck
other
Other complications
Birthweight pounds
Ounces
Please enter a number from
0
to
16
.
Apgar Scores
and
Post Delivery:
Cyanosis
Yes
No
Infection
Yes
No
Other Illnesses or problems
How many days was your child in the hospital nursery before being discharged home?
Difficulty with feeding?
Yes
No
If yes, please explain
Developmental and Medical History
Age child crawled:
sat
walked
Did your child walk prior to 15 months?
Yes
No
Age child said first word
and talked in 2-3 word sentences
Did your child speak first words (mama, dada) prior to 12 months?
Yes
No
Did your child speak in 2-3 word sentences prior to 2 years old?
Yes
No
Does your child use gestures to help communicate his or her wants and needs?
Yes
No
Age child was toilet trained (day)
(night)
Do accidents still occur during the day?
Yes
No
Do accidents still occur at night?
Yes
No
Did your child receive Early Intervention (EI) services prior to age 3?
Yes
No
Select which type of EI he/she received:
Speach
Occupational
Physical
Did your child receive interventions after age 3 through the school or privately?
Yes
No
Select which type of intervention:
Speech
Occupational
Physical
Does your child show any of these conditions?
Attention Problems
Head Injury
Muscle Tightness or Weakness
Clumsiness
Hearing Problems
Speech Problems
Frequent Ear Infections
Learning Disability
Behavior Issues
Other conditions
Has your child ever been tested for developmental disabilities (e.g., cerebral palsy, specific learning disabilities, autism, ADHD, etc.)?
Yes
No
MEDICAL HISTORY:
Please list past and current medical conditions
Has your child ever been hospitalized?
Yes
No
Describe:
Has your child ever suffered a serious injury to their head?
Yes
No
Describe head injury
Please note all medications taken at present, their dosage, and frequency given. Example: Depakote 100 mg. 2 tablets/ AM, 1.5 tablets/ afternoon, 4 tablets/ evening.
FAMILY HISTORY:
Please check all that existed in close biological family members (parents, brothers, sisters, grandparents, aunts, uncles), note who it was, and describe the problem indicated:
Neurological/Brain condition
Who
Describe
Learning Disability
Who
Describe
Mental Retardation
Who
Describe
ADHD
Who
Describe
Alcohol/Drug Dependency
Who
Describe
Bipolar Disorder
Who
Describe
Depression
Who
Describe
Personality Disorder
Who
Describe
Schizophrenia
Who
Describe
Other Psychiatric Illness
Who
Describe
Other Disease/ Disorder
Who
Describe
PSYCHOSOCIAL HISTORY:
People living in household with child – Name, Age, Relationship – one per line)
Would you consider the current living situation/environment stressful?
Yes
No
Maybe
What is your child’s best attribute/characteristic (e.g. , friendly, hard worker)?
What is your child’s worst attribute/characteristic (e.g. , stubborn, quick tempered)?
Describe any organizations, volunteering, hobbies, reading interests, or other leisure-time activities in which your child is currently engaged in:
Has your child ever been under the care of a psychiatrist, psychologist, or counselor?
Yes
No
If Yes, what were they seen for?
Are they currently under the care of:
psychiatrist
psychologist/counselor
EDUCATIONAL HISTORY:
Name of School
County
Classroom placement
regular placement
special placement
Explain
Is your child being homeschooled?
Yes
No
Since when?
Typical grades on report card
Has your child repeated any grades?
Yes
No
If so, which grade(s) repeated?
Has your child skipped any grades?
Yes
No
If so, which grade(s) skipped?
Easiest subjects
Difficult subjects
Has your child ever had an IEP?
Yes
No
Section 504 plan?
Yes
No
Your child’s IEP/504 is designated under which category at school?
Unknown
Autism
Other Health Impaired
Specific Learning Disability (SLD)
Speech/ Language Impairment (SLI)
Traumatic Brain Injury (TBI)
Emotional Disturbance
Mental Retardation
Orthopedic
Deaf/Hearing/Visual/Deaf-Blindness
Multiple
During which grade was the IEP established?
Educational tutoring/Remedial activities (if any)
Describe any school problems
SUBSTANCE USE HISTORY:
Please check all the drugs your child/adolescent is using or have used in the past:
Alcohol
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Tobacco
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Caffeine
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Amphetamines (including diet pills)
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Barbiturates (downers)
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Cocaine or crack
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Hallucinogens/ LSD
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Inhalants (glue, spray cans, etc.)
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Marijuana
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Opiate narcotics
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
PCP (angel dust)
Not using
Presently using
Used in the past
Date
MM slash DD slash YYYY
Other drugs
Not using
Presently using
Used in the past
(drug name)
Date
MM slash DD slash YYYY
Δ
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