Psychiatric Development - English (rev 20200504) PSYCHIATRIC EVALUATION HISTORY Client name* First Last Date of birth* MM slash DD slash YYYY Pediatrician/Primary care provider Date of last physical MM slash DD slash YYYY Is the child currently on any psychotropic medications?* Yes No Don't know If yes, please list known psychotropic medicationsIs the child currently taking any prescription or Over-the-Counter medication (including supplements e.g. vitamins, herbs, CBD, etc.)* Yes No Don't know If yes, list known prescriptions or over-the-counter medications:Medical History Has the child ever : Had a concussion* Yes No Don't know Been hospitalized overnight* Yes No Don't know Been diagnosed with a chronic medical condition* Yes No Don't know Been in a serious accident* Yes No Don't know Had surgery* Yes No Don't know Family medical historyDoes anyone in the family have (or had) any of the following conditions?Developmental delays* Yes No Don't know Learning problems, such as dyslexia or poor reading* Yes No Don't know Autism or Asperger’s Syndrome* Yes No Don't know Attention Deficit (ADD/ADHD)* Yes No Don't know Tics or Tourette syndrome* Yes No Don't know Depression or anxiety* Yes No Don't know Suicidal thoughts or behaviors* Yes No Don't know Schizophrenia or bipolar disorder* Yes No Don't know Gambling issues* Yes No Don't know Alcohol overuse* Yes No Don't know Other substance use concerns* Yes No Don't know Cardiac disease, including sudden death* Yes No Don't know Diabetes* Yes No Don't know Migraine or other chronic headache* Yes No Don't know Thyroid disease* Yes No Don't know Weight management issues* Yes No Don't know Cancer* Yes No Don't know Other major medical illness* Yes No Don't know Developmental HistoryDid mother have prenatal care?* Yes No Don't know Medical or psychiatric problems during pregnancy?* Yes No Don't know Medications during pregnancy?* Yes No Don't know Nicotine during pregnancy?* Yes No Don't know Other substance use during pregnancy?* Yes No Don't know Problems with eating/sleeping in infancy?* Yes No Don't know Any allergies or reflux in infancy?* Yes No Don't know Delays in crawling/walking?* Yes No Don't know Delays in toileting?* Yes No Don't know Delays in speech?* Yes No Don't know Problems learning letters/reading?* Yes No Don't know Problems learning numbers/math?* Yes No Don't know Did child attend preschool?* Yes No Don't know Any social problems in preschool?* Yes No Don't know Developmental DetailsWeeks gestation at birth Length of labor Was delivery vaginal or c-section? Problems during labor/delivery? Infant weight at birth Problems at birth? (Ex: given oxygen, put in incubator) Has the child had any of the following services?Birth to Three* Past Current Never Don't know School accommodations (IEP or 504 plan)* Past Current Never Don't know Psychological testing (in school)* Past Current Never Don't know Psychological or neuropsychological testing (outside of school)* Past Current Never Don't know Occupational Therapy* Past Current Never Don't know Speech-Language Therapy* Past Current Never Don't know Applied Behavioral Analysis (ABA)* Past Current Never Don't know Psychiatry* Past Current Never Don't know Individual therapy* Past Current Never Don't know Group therapy* Past Current Never Don't know Family therapy* Past Current Never Don't know Intensive Outpatient or Partial Hospital Program* Past Current Never Don't know In-home programs (MDFT, FFT, IICAPS)* Past Current Never Don't know Substance use treatment* Past Current Never Don't know Psychiatric hospitalization* Past Current Never Don't know Court-mandated mental health treatment* Past Current Never Don't know OtherReview of SystemsOther than information provided above, does the child have any other conditions?General health, such as energy level, difficulty gaining weight, or overweight* Past Current Never Don't know Sleep issues (including snoring)* Past Current Never Don't know Eyes or vision* Past Current Never Don't know Ears or hearing* Past Current Never Don't know Ears or hearing* Past Current Never Don't know Mouth or teeth/dental* Past Current Never Don't know Breathing or respiration, including asthma* Past Current Never Don't know Heart or cardiovascular/circulation* Past Current Never Don't know Digestion or gastrointestinal, including food sensitivities* Past Current Never Don't know Elimination/urination/peering or genitourinary* Past Current Never Don't know Muscles/bones or musculoskeletal* Past Current Never Don't know Nerves/brain or neurological, such as starting spells, shaking, or seizures* Past Current Never Don't know Skin, including eczema, birthmarks, or rashes* Past Current Never Don't know Endocrine or hormones* Past Current Never Don't know Blood or hematologic* Past Current Never Don't know Behavior, including lying, stealing, setting fires, or cruelty to animals* Past Current Never Don't know For female children:Has the child started menstruation? Yes No If menstruation started, at what age? Are periods regular? Yes No Any mood concerns associated with cycle? Yes No Receive copy of this form (optional) You may receive a copy of this completed form in an email. Please be aware this form contains names, dates of birth, and policy numbers. This information is considered Protected Health Information and belongs to you. Email is not a secure method to receive this information. Only request this completed form if you understand the risk associated with email. You may request this completed form at any time by contacting the Child and Family Agency. See our contact information on our website. Send the completed form by email.* I understand the risk and assume responsibility. Do not send the completed form by email. Email* Enter Email Confirm Email
