Child intake questions

Child intake questions
Developmental and Social History
Name *

First Name Last Name
Date of birth *

Month Day Year
Date
Person completing this form

First Name Last Name
Relationship to child
Today's date

Month Day Year
Date

Family composition

	Parent’s Name	Birth Date	Birth Place	Education	Occupation
Parent 1
Parent 2

	Children in order of birth	Sex	School Attended	Grade
1
2
3
4
5
6
7
8

	Others in household	Relationship	Age	Occupation
1
2

Age of parents at birth of child:
Mother
Father
Prenatal (Pregnancy)
Is there a known blood incompatibility between parents?

Yes No
Did the mother have any serious health problems or injuries during pregnancy? (e.g. Hepatitis, Measles, Toxemia, Anemia, Uterine bleeding, an accident or fall)

Yes No
If yes, identify the problem
Were x-rays taken?

Yes No
Was mother under medication?

Yes No
Length of pregnancy was blanks months
Perinatal (Birth)
Labor was:

Uncomplicated Induced Prolonged Difficult Other
Delivery was:

Uncomplicated By forceps Caesarean Other
Birth weight was: blanks lbs
Immediately after birth the baby:

Did not cry spontaneously Was jaundiced Was given oxygen Was given a transfusion Was placed in an incubator Other
Developmental Milestones
Would you consider the child as having been “late” in any of the following areas?

Lifting head Sitting up Standing alone Walking Making speech noises Talking
At present, the child is self-sufficient for:

Feeding Toilet care Dressing Bathing
The child is right or left handed:

Right Left
Medical Health History
Has the child had a convulsion or seizure?

Yes No
If yes, please indicate date of onset, frequency, date of last seizure, probable cause
Characteristics of seizure
Has the child had any evidence of ear/hearing problems?

Yes No
If yes, please state the problem and treatment
Has the child had any evidence of eye/vision problems?

Yes No
If yes, please state the problem and treatment
In addition to those previously mentioned, has the child been hospitalized for illness or surgery?

Yes No
If yes, please explain
Has the child experienced any changes in behavior as a result of illness or injury?

Yes No
If yes, please explain

Does the child have problems with any of the following (please check if appropriate)?

	Check box if yes
Constipation
Diarrhea
Nausea/Vomiting
Poor appetite
Underweight
Overweight
Skin itching
Nose bleed
Bedwetting
Nail biting
Nervousness
Colds
Headaches
Dizziness
Insomnia
Fatigue
Coordination

In addition to the above, does the child have any, chronic health concerns such as allergies, anemia, asthma, diabetes, skin problems, heart condition, orthopedic problems, etc.?

Yes No
Problem blanks
Date of onset blank
Severity of condition Type a label
Treatment Type a label
Is the child presently under medication?

Yes No
If yes, please list
Name of medication(s) blanks
How often it is given blank
Physician ordering medication Type a label
Has the child had a severe or unusual illness? (these would include encephalitis, meningitis, etc.)

Yes No
If yes, please state illness and date(s):
Has the child had a severe injury/ (Broken bones; head injury, etc.)?

Yes No
If yes, please state date and nature of injury
Did the child lose consciousness?

Yes No
Please list the names of all professionals who have examined the child such as pediatrician, neurologist, optometrist, dentist, psychiatrist, psychologist, speech pathologist, educational specialist, audiologist, etc., and give month/year date of the most current evaluation.
Current pediatrician or health care provider, please give name, address and telephone number:
Social History
How does the child get along with his/her brothers/sisters?

Doesn’t have any Better than average Average Worse than average
How easily does the child make friends?

Doesn't have any Better than average Average Worse than average
How does the child get along with teachers and others?

Easier than average Average Worse than average Unsure
What strategies have been implemented to address these problems (Check which have been successful)

Verbal reprimands Time out(isolation) Removal of privileges Rewards Physical punishment Acquiescence to child Avoidance of child
On the average, what percentage of the time does your child comply with initial commands?

0-20% 20-40% 40-60% 60-80% 80-100%
To what extent are you and your significant other consistent with respect to disciplinary strategies?

Most of the time Some of the time None of the time
Diagnostic Criteria
Which of the following are considered to be significant problems at the present time?

Fidgets Difficulty remaining seated Easily distracted Often blurts out answers to questions before they have been completed Difficulty following instructions Difficulty sustaining attention Shifts from one activity to another Difficulty playing quietly Often talks excessively Often interrupts or intrudes on others Often does not listen Often loses things Often engages in physically dangerous activities
Which of the following are considered to be a significant problem at the present time?

Often loses temper Often argues with adults Often actively defies or refuses adult requests or rules Often deliberately does things that annoy other people Often blames others for own mistakes Is often touchy or easily annoyed by others Is often angry or resentful
Which of the following are considered to be a significant problem at the present time?

Unrealistic and persistent worry about possible harm to attachment figure Unrealistic and persistent worry that a calamitous event will separate the child from attachment figure 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 from home or attachment figure
Which of the following are considered to be a significant problem at the present time?

unrealistic worry about future events unrealistic concern about appropriateness of past behavior marked self-consciousness excessive need for reassurance marked inability to relax
Which of the following are considered to be a significant problem at the present time?

Depressed or irritable mood of day, nearly every day Diminished pleasure in activities; Decrease or increase in appetite assoc. with possible failure to make weight gain Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive inappropriate guilt Diminished ability to concentrate
Which of the following are considered to be a significant problem at the present time?

Depressed or irritable mood for most of day for the last year Poor appetite or overeating Low self-esteem Poor concentration or difficult making decisions Feelings of hopelessness Never without symptoms for > 2 months over a 1-year period
Has the child exhibited any symptoms of:

Excessive lability w/o reference to the environment Explosive temper with minimal provocation Excessive clinging, attachment, or dependence on adults Unusual fears Strange aversions Panic attacks Excessively constricted or bland affect Situationally inappropriate emotions
Should be Empty:

Child intake questions

Developmental and Social History

Prenatal (Pregnancy)

Perinatal (Birth)

Developmental Milestones

Medical Health History

Social History

Diagnostic Criteria