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forms – Psychiatric Development

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 medications
Is 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 history
Does 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 History
Did 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 Details
Weeks 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
Other
Review of Systems
Other 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
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