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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:
Yes
No
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
Yes
No
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
Yes
No
Pediatrician Name
Pediatrician Phone number
Date of last Pediatrician
Physical exam
Date of last Dental exam
Date of last Vision exam
Additional healthcare providers
Yes
No
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?
Yes
No
Can child catch a ball?
Yes
No
Child had no trouble learning to hold a pencil?
Yes
No
Child easily learned to zip to zippers, tie shoes and button clothes?
Yes
No
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
Yes
No
Promoting self-care appropriate for age level
Yes
No
Does the child drink alcohol?
Yes
No
Smoking Status : Vaping
Yes
No
Others smoking in home
Yes
No
Educational History : Highest grade level completed
Current grade
Name of school presently attending
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
Submit
