Child Questionnaire

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Presenting Problem *

Please briefly describe reason for this visit

Current Medications

Please list current medications and daily dosage, including over the counter meds, vitamins, herbs, and supplements:

Past Psychiatric Medications :

Please list any previous medications, including how long the medication was taken, beneficial effects, side effects, and reason discontinued

Medication

Benefits

Side Effects

Reason Discontinued

Time

Allergies/Adverse Reactions: *

Behavioral Health History:

Has the client had past or current outpatient behavioral health treatment

Individual Therapy

Provider/Date

Family Therapy

Provider/Date

Medical Management

Provider/Date

Psychological Testing

Provider/Date

Psychiatric Hospital Admission

Provider/Date

Additional Behavioral Health

Provide Additional Behavioral Health History

Current Living Situation

Who is living in the home and their relationship to the patient

Cultural / Ethical / Spiritual Considerations / Identities

Unknown Family History / Child is Adopted

Does the child or a family member have a history of prior diagnosis of ADD/ADHD

Child
Family Member
Bro/sis/mom/dad/other

Autism Spectrum Disorder

Child
Family Member
Bro/sis/mom/dad/other

Bipolar Disorder

Child
Family Member
Bro/sis/mom/dad/other

Depression

Child
Family Member
Bro/sis/mom/dad/other

DMDD

Child
Family Member
Bro/sis/mom/dad/other

Eating Disorder

Child
Family Member
Bro/sis/mom/dad/other

Encopresis/Enuresis

Child
Family Member
Bro/sis/mom/dad/other

Generalized Anxiety

Child
Family Member
Bro/sis/mom/dad/other

Learning Disability

Child
Family Member
Bro/sis/mom/dad/other

Mania

Child
Family Member
Bro/sis/mom/dad/other

Obsessive-Compulsive Disorder

Child
Family Member
Bro/sis/mom/dad/other

Oppositional Defiant Disorder

Child
Family Member
Bro/sis/mom/dad/other

Panic Attacks

Child
Family Member
Bro/sis/mom/dad/other

PTSD/Trauma

Child
Family Member
Bro/sis/mom/dad/other

Schizophrenia

Child
Family Member
Bro/sis/mom/dad/other

Separation Anxiety

Child
Family Member
Bro/sis/mom/dad/other

Substance Use/Dependence

Child
Family Member
Bro/sis/mom/dad/other

Tourette’s

Child
Family Member
Bro/sis/mom/dad/other

Other

Please Specify

Medical History : Pediatrician

Pediatrician Name

Pediatrician Phone number

Date of last Pediatrician

Physical exam

Date of last Dental exam

Date of last Vision exam

Additional healthcare providers

Has the child received immunizations?

Yes
No
Unknown

Are the child’s immunizations up to date?

Yes
No
Unknown

Has the child or a family member been diagnosed with Anemia?

Child
Family Member
Bro/sis/mom/dad/other

Asthma

Child
Family Member
Bro/sis/mom/dad/other

Cancer/Leukemia

Child
Family Member
Bro/sis/mom/dad/other

Cerebral Palsy

Child
Family Member
Bro/sis/mom/dad/other

Diabetes

Child
Family Member
Bro/sis/mom/dad/other

Down’s Syndrome

Child
Family Member
Bro/sis/mom/dad/other

Ear Infection

Child
Family Member
Bro/sis/mom/dad/other

Encephalitis

Child
Family Member
Bro/sis/mom/dad/other

Epilepsy/Seizures

Child
Family Member
Bro/sis/mom/dad/other

Fever above 150

Child
Family Member
Bro/sis/mom/dad/other

Hearing Problems

Child
Family Member
Bro/sis/mom/dad/other

Heart Problems/Disease

Child
Family Member
Bro/sis/mom/dad/other

HIV/AIDS

Child
Family Member
Bro/sis/mom/dad/other

Hydrocephalus

Child
Family Member
Bro/sis/mom/dad/other

Lead Poisoning

Child
Family Member
Bro/sis/mom/dad/other

Liver Disease

Child
Family Member
Bro/sis/mom/dad/other

Loss of Consciousness/Head Injury Meningitis

Child
Family Member
Bro/sis/mom/dad/other

Musculo-Skeletal Condition

Child
Family Member
Bro/sis/mom/dad/other

Strep Infection

Child
Family Member
Bro/sis/mom/dad/other

Stroke

Child
Family Member
Bro/sis/mom/dad/other

Thyroid Problems

Child
Family Member
Bro/sis/mom/dad/other

Vision Problems

Child
Family Member
Bro/sis/mom/dad/other

Other

Please specify

Does the child have an eating or sleeping problem ?

Dieting
Overeating
Undereats
Picky eater
Recent weight gain
Recent weight loss
Refuses to eat
Vomiting
Bedwetting
Difficulty falling asleep
Does not want to sleep alone
Sleeps too much
Nightmares
Soiling
Trouble staying asleep
Restless at night

Other

Specify eating or sleeping problem

How would you describe the nutritional value and balance of the child’s diet?

Good
Fair
Poor

Breakfast

Lunch

Dinner

Does the child have Cognitive Issues?

Lack of varied, spontaneous make-believe play
Restricted patterns of behavior, activities, or interests
Repetitive patterns of behavior, interest, or activities
Preoccupation with parts of an object
Cognitive disabilities
Intense/all-encompassing interest

Does the child have Sensory Issues?

Sensory Issues
Other sensory issues
Coordination problems

Developmental History

Health of mother during pregnancy

Good
Fair
Poor
Unknown

Parental ages at time of birth: Mother

Parental ages at time of birth: Father

Did mother use any of the following during pregnancy?

Cigarettes
Alcohol
Coffee/caffeine drinks
Cocaine/crack
Marijuana

Please list prescription drugs

Any medical complications during pregnancy?

Yes
No
Unknown

Length of pregnancy

Full term
Late preterm (32-36 weeks)
Very preterm (28-31 weeks)
Extremely preterm (less than 28 weeks)
Unknown

Birth Weight

Were the any complications during or following birth?

Baby given oxygen
Baby on heart monitor
Birth defects
Blood transfusions
Delivery aided by instruments
Delivery by cesarean section
Incubator
Jaundice
Problems breathing
Problems eating/digestion
Problem sucking
Rashes
Very active
Very quiet

Other complications during birth?

Early Development : What age did the child begin walking?

Months

What age did the child begin talking?

Single word

What age did the child begin talking?

short sentences 2+ words

What age did the child begin running?

months

What age did the child begin toilet training day-time?

What age did the child begin toilet training night-time?

Can child throw a ball?

Can child catch a ball?

Child had no trouble learning to hold a pencil?

Child easily learned to zip to zippers, tie shoes and button clothes?

During the first three years of life, the child frequently exhibited:

Accident prone behavior
Avoidance of cuddling
Colic
Distractibility
Extreme mood changes
Problems with sleeping/walking patterns
Feeding problems
Lack of coordination
Overactive behavior
Restless behavior
Self-hurting behavior
Temper tantrums
Head banging
Unresponsive to discipline

Activities of Daily Living : Assigned chores or responsibilities

Promoting self-care appropriate for age level

Does the child drink alcohol?

Smoking Status : Vaping

Others smoking in home

Educational History : Highest grade level completed

Current grade

Name of school presently attending

School related issues

504 plan
Advanced a grade
Academic problems
Attendance
Behavior
Bullying
Detention
Expulsion
IEP
Held back a grade
Homework
Learning disabilities
Met with school counselor
Occupational therapy
Peer relationships
Physical therapy
Relationships with teacher(s)
Required special help
School modifications
Speech therapy
Suspension (in school)
Suspension (out of school)
Tested by school psychologist (ADD, ADHD, other)
Transportation

Please describe and include any additional educational stressors

Additional Social History : How easy is it for the child to make friends?

More difficult
Average
Easier than average

How does the child get along with siblings?

More difficult
Average
Easier than average

What are the child’s strengths?

Please describe extracurricular activities, employment and other pertinent information.

Relationship to patient *

Self
Parent
Guardian
Other

Child Questionnaire

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