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FIRST NAME
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LAST NAME INITIAL
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Date and time of your appointment
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DOB MM/DD/YYYY
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REASON FOR THE
CONSULTATION
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Have you noticed your child has been having problems with any of the following
symptoms?
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Sadness or irritability ?
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NO
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YES
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Losing interest in daily activities ?
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NO
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YES
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Tiredness ?
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NO
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YES
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Poor self-esteem ?
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NO
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YES
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Difficulty with concentration ?
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NO
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YES
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Restlessness or being slowed down ?
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NO
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YES
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Problems with sleeping too much or not sleeping?
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NO
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YES
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Problems with weight loss or weight gain ?
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NO
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YES
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Thoughts of death, suicidal thoughts ?
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NO
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YES
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Careless mistakes when at work or doing chores around the house ?
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NO
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YES
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Difficulty focusing on one thing for a long time ?
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NO
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YES
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Not listening when spoken to directly?
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NO
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YES
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Difficulty finishing things ?
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NO
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YES
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Difficulty organizing tasks and activities ?
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NO
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YES
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Losing things necessary for tasks and activities?
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NO
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YES
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Being forgetful in daily activities ?
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NO
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YES
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Reluctance o engage in tasks that require sustained attention: homework, schoolwork ?
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NO
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YES
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Difficulty sitting still, fidgeting ?
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NO
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YES
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Leaving seat in classroom or in other situations in which remaining seated is expected?
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NO
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YES
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Running about or climbing excessively ?
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NO
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YES
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Difficulty playing quietly ?
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NO
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YES
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Being on the go, doing something ?
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NO
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YES
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Talking excessively ?
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NO
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YES
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Blurting out answers before questions have been completed?
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NO
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YES
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Difficulty awaiting turn ?
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NO
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YES
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Interrupting or intruding on others ?
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NO
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YES
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Bad temper, temper tantrums ?
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NO
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YES
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Frequently arguing with parents or teachers ?
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NO
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YES
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Defying or refusing to comply with adults' requests or rules ?
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NO
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YES
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Deliberately annoying people ?
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NO
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YES
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Blaming others for mistakes or misbehavior ?
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NO
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YES
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Being easily annoyed by others?
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NO
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YES
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Being angry and resentful?
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NO
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YES
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Being spiteful or vindictive ?
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NO
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YES
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Have your child ever taken any of the following medications ?
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NAME
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NO
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YES
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RESPONSE, SIDE EFFECTS
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Ritalin
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Dexedrine
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Concerta
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Metadate CD
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Adderall
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Focalin
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Daytrana
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Strattera
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Clonidine
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Tenex
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Buproprion ( Wellbutrin )
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Mirtazapine ( Remeron)
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Citaprolam ( Celexa)
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Escitaprolam ( Lexapro)
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Fluoxetine ( Prozac)
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Sertaline ( Zoloft)
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Paroxetine ( Paxil)
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Fluvoxamine ( Luvox)
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Venlafaxine ( Effexor)
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Duloxetine ( Cymbalta)
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Lithium
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Valproate ( Depakote)
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Lamotrigine ( Lamictal)
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Risperidone ( Risperdal)
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Olanzapine ( Zyprexa)
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Quetiapine ( Seroquel)
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Aripiprazole ( Abilify)
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Ziprasidone ( Geodon)
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Please, check if any of the following family members has a history of the following
problems?
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MOTHER
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Father
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Sister (s)
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Brother(s)
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Maternal
Grand
mother
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Maternal
Grand
father
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Paternal
grand
mother
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Paternal
grand
father
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Any
Blood
relative
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Anxiety
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Depression
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Bipolar
(Manic)
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Alcohol
Abuse
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Drug
Abuse
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Schizophrenia
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ADHD/
ADD
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Suicidal
Behavior
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Psychiatric
Hospitalization
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PRENATAL HISTORY OF THE CHILD
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How many times the biological mother was
pregnant ?
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Was there any history of previous miscarriage ?
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What is the number of living children in case of
the biological mother?
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Was there any exposure to nicotine, alcohol ,
drugs during pregnancy with the patient ?
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Was there any medical problem during
pregnancy in case of the biological mother -
diabetes, high blood pressure, infections ?
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Did the biological mother take any medications
during pregnancy?
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Duration of pregnancy in weeks ?
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BIRTH HISTORY
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What was the method of delivery ? ( vaginal,
forceps, Caesarean ?)
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Duration of labor ?
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Was there any complication during labor ?
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Birth weight of the baby ?
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Did the baby remained in the hospital longer
than mother?
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DEVELOPMENTAL HISTORY
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At what age did the child walk?
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At what age did the child talk single words ?
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At what age did the child talk in sentences ?
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At what age did the child toilet train?
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Any history of bed wetting?
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EDUCATIONAL HISTORY
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A
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B
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C
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D
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F
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Pre-Kindergarten
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Kindergarten
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Grade 1
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Grade 2
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Grade 3
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Grade 4
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Grade 5
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Grade 6
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Grade 7
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Grade 8
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Grade 9
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Grade 10
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Grade 11
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Grade 12
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LIVING SITUATION
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With whom did your child live between the age
0 - 5 ?
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With whom did you child live between the age
5 - 10 ?
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With whom did your child live between the age
10 -15 ?
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Have your child been suffering from any of the following medical problems ?
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EYEs/EARS/
NOSE/Mouth/
THROAT
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Any visual problems ?
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Any hearing problems ?
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Frequent throat infections ?
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Frequent sneezing and nasal congestion ?
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Any other problems involving ears, eyes, nose,
mouth and throat ?
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HEART and
Blood Vessels
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Heart murmur ?
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Hypertension (High Blood Pressure)?
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Heart Defect ?
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Heart Arrhythmia - Irregular heart beat
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Other Heart Problems
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Lungs
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Asthma
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Bronchitis, pneumonia ?
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Other lung problems
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Stomach,
Intestines,
Liver,
Pancreas
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Frequent abdominal pain ?
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Frequent vomiting or diarrhea ?
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Other stomach, intestinal, liver or pancreas problems
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Kidneys and
Urinary Tract
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Any problems with kidneys or bladder ?
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Muscles/ Bones
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Arthritis
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Other problems with muscles, bones and joints
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Nervous System
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Frequent headaches ?
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Seizures, Epilepsy ?
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Fainting ?
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Other
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Hormones and
Metabolism
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Diabetes
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Thyroid problems
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Other hormonal problems
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Skin
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Acne, eczema, atopic dermatitis ?
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Blood
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Anemia and Other
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Allergies
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Seasonal allergies
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