Professional Documents
Culture Documents
GENERAL INFORMATION:
Child’s place of birth:
Mother’s Name: Work/cell number:
REFERRAL INFORMATION:
Referred by:
What concerns you about your child (if different than the reason for the consultation:
EDUCATIONAL/CULTURAL INFORMATION:
In what ways do you feel you would best be able to learn about your child’s treatment? (Check all that apply)
□ Demonstration □ Instruction with Return Demonstration □ Verbal Information
□ Written Information □ Other:
Do you have any religious or cultural needs related to you child’s care to which we need to be aware? (i.e. diet, religious
practices) □ Yes (if yes, please explain below) □ No
PREGNANCY/BIRTH HISTORY:
Was the child born on time? Y N; if no: weeks early/ weeks late
Child’s birth weight: Regular Nursery OR Intensive Care Nursery (circle one)
Were you given any drugs to easy the pain during labor? Y N (If yes, which drug: )
During the pregnancy, did any of the following occur (please circle all that apply):
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TEMPERAMENT:
Was the child an easy baby meaning did he/she cry a lot? Did she follow a schedule fairly well?
□ More sociable than average □ Average sociability □ More unsociable than average
□ Very insistent □ Pretty Insistent □ Average □ Not very insistent □ Not insistent at all
How would you rate the activity level of the child as an infant/toddler?
DEVELOPMENTAL HISTORY:
Please indicate the age at which your child did the following:
Does your child have any difficulty performing age appropriate activities listed below? (Please check all that apply)
HANDEDNESS:
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MEDICAL HISTORY:
____________________________________________________________________________________________________
Has your child ever had a head injury requiring medical attention?
Did you notice any long standing problems after the injury?
If yes, please describe:
Describe other Medical conditions/problems not listed above: ____________________________________________________
Is your child being seen by any doctor/medical personnel other than a pediatrician/family practitioner? (if yes, please check all
that apply):
□ Neurosurgeon □ Physical Therapist □ Dentist
□ Neurologist □ Psychologist/Psychiatrist □ Rheumatologist
□ Ear, Nose & Throat □ Occupational Therapist □ Speech Therapist
□ Other:
□ For what reason do you see the above practitioner? _______________________________________________
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Has your child had any chronic health problems (e.g. asthma, diabetes, heart condition)?
□ Yes □ No
____________________________________________________________________________________________________
At what age was the onset of any chronic illness?
EDUCATIONAL HISTORY:
Please summarize you child’s progress (e.g. academic, social, and testing) within each of these grade levels:
Preschool:
Kindergarten:
Grades 1-3:
Grades 4-6:
Grades 7-12:
Has your child ever been evaluated by a child study team? Y N When?
Does your child have a 504 plan in place? Y N Does your child have an IEP? Y N
Has your child ever been in and type of special education program, and if so, how long?
Does your child receive any services in school? (Please check all that apply)
Has your child ever been prescribed any of the following? Please list duration in months next to medication.
Has your child ever had any of the following forms of psychological treatment? Please list duration next to the
treatment.
Please list the start date and current frequency for the following (if applicable):
Physical Therapy: times per week Occupational Therapy: times per week
Speech Therapy: times per week Counseling: times per month
Please list the dates and results for the following (if applicable):
Child study team: Does child attend resource room? Y N Receive basic skills? Y N
EEG: CT scan or MRI:
Other evaluations:
FAMILY HISTORY:
Parents’ marital status (circle one): Married Separated Divorced Living Together
Other_________________________________________________
Mother:
Occupation:
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Name of mother’s parents, sisters, brothers, nieces, and nephews with problems similar to your child:
Father:
Occupation:
Name of mother’s parents, sisters, brothers, nieces, and nephews with problems similar to your child: ____
____
SOCIAL HISTORY:
Please list below the names and ages of all individuals living in the household:
Name Age
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Does the place where you child lives have any of the following? (Please check all that apply):
□ Elevator □ Ramp
□ Stairs, no rail □ Stairs, rail
□ Other obstacles:
Does your child utilize any of the following specialized equipment? (Please check all that apply):
□ Other:
Is your child involved in any community activities? If yes, please list below:
□ Clubs:
□ Sports:
□ Other:
Does your child receive any special services? If yes, please list below:
Does your child use a car/booster seat? (for children under 80 lbs.) Y N
Please list all grades that were repeated: Grade in which school difficulty first arose?:
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Does your child have any health problems that could impact on services?
Is there any significant family history that could impact on your child’s services?
On the average, what percentage of the time does your child comply with initial commands?
To what extent are you and your spouse consistent with respect to disciplinary strategies?
Have any of the following “stress events” occurred within the past 12 months?
□ Often loses temper □ Often argues with adults □ Often blames others for own
mistakes
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□ Is often angry or resentful □ Is often spiteful or vindictive □ Often swears or uses obscene
language
□ Often actively defies or refuses adult □ Is often touchy or easily annoyed by □ Often deliberately does things that
requests of rules. others annoy other people
□ Persistent school refusal □ Persistent refusal to sleep alone □ Persistent avoidance of being alone
□ Repeated nightmares re: separation □ Somatic complaints □ Excessive distress in anticipation of
separation from attachment figure
□ Excessive distress when separated □ Unrealistic and persistent worry about □ Unrealistic and persistent worry that a
from attachment figure possible harm to attachment figures calamitous even will separate the
child from attachment figure
□ Unrealistic worry about future events □ Somatic complaints □ Marked inability to relax
□ Marked self-consciousness □ Excessive need to reassurance □ Unrealistic concern about
competence
□ Unrealistic concern about
appropriateness of past behavior
□ Depressed or irritable mood most of □ Diminished pleasure in activities □ Decrease or increase in appetite
the day, nearly every day associated with possible failure to
make weight gain
□ Insomnia or hypersomnia nearly □ Psychomotor agitation or retardation □ Fatigue or loss of energy
every day
□ Feelings of worthlessness or □ Diminished ability to concentrate □ Suicidal ideation or attempt
excessive inappropriate guilt
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□ Depressed or irritable mood for most □ Poor appetite or overeating □ Insomnia or hypersomnia
of the day x1 year
□ Low energy or fatigue □ Low self-esteem □ Poor concentration or difficulty
making decisions
□ Feelings of hopelessness □ Never without symptoms for > 2
months over a 1-year period
OTHER CONCERNS:
TOTAL=
□ Loose thinking (e.g., tangential ideas, □ Bizarre ideas (e.g., odd fascinations, □ Disoriented, confused, staring, or
circumstantial speech) delusions, hallucinations) “spacey”
□ Incoherent speech (mumbles, jargon)
TOTAL=
□ Excessive lability w/o reference to □ Explosive temper with minimal □ Excessive clinging, attachment, or
environment provocation dependence on adults
□ Unusual fears □ Strange aversions □ Panic attacks
□ Excessively constricted or bland □ Situationally inappropriate emotions
affect
TOTAL=
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Which of the following are considered to be a problem for your child at the present time?
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PATERNAL RELATIVES:
For the following, please indicate if the statement or condition to the left corresponds to any of the family members listed.
SIBLINGS
TOTAL
Self Mother Father Bro Bro Sis Sis
Learning disabilities □ □ □ □ □ □ □
Mental retardation □ □ □ □ □ □ □
Psychosis or schizophrenia □ □ □ □ □ □ □
Tics or Tourette’s □ □ □ □ □ □ □
Alcohol abuse □ □ □ □ □ □ □
Substance abuse □ □ □ □ □ □ □
Arrests □ □ □ □ □ □ □
Physical abuse □ □ □ □ □ □ □
Sexual abuse □ □ □ □ □ □ □
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MATERNAL RELATIVES:
For the following, please indicate if the statement or condition to the left corresponds to any of the family members listed.
SIBLINGS
TOTAL
Self Mother Father Bro Bro Sis Sis
Learning disabilities □ □ □ □ □ □ □
Mental retardation □ □ □ □ □ □ □
Psychosis or schizophrenia □ □ □ □ □ □ □
Tics or Tourette’s □ □ □ □ □ □ □
Alcohol abuse □ □ □ □ □ □ □
Substance abuse □ □ □ □ □ □ □
Arrests □ □ □ □ □ □ □
Physical abuse □ □ □ □ □ □ □
Sexual abuse □ □ □ □ □ □ □
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SIBLINGS:
For the following, please indicate if the statement or condition to the left corresponds to any of the family members listed.
TOTAL
Brother Brother Sister Sister
Learning disabilities □ □ □ □
Mental retardation □ □ □ □
Psychosis or schizophrenia □ □ □ □
Tics or Tourette’s □ □ □ □
Alcohol abuse □ □ □ □
Substance abuse □ □ □ □
Arrests □ □ □ □
Physical abuse □ □ □ □
Sexual abuse □ □ □ □
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