Child intake questions

Child intake questions
Developmental and Social History
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Person completing this form

First NameLast Name
Relationship to child
Today's date

MonthDayYear
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?

YesNo
Did the mother have any serious health problems or injuries during pregnancy? (e.g. Hepatitis, Measles, Toxemia, Anemia, Uterine bleeding, an accident or fall)

YesNo
If yes, identify the problem
Were x-rays taken?

YesNo
Was mother under medication?

YesNo
Length of pregnancy was blanks months
Perinatal (Birth)
Labor was:

UncomplicatedInducedProlongedDifficultOther
Delivery was:

UncomplicatedBy forcepsCaesareanOther
Birth weight was: blanks lbs
Immediately after birth the baby:

Did not cry spontaneouslyWas jaundicedWas given oxygenWas given a transfusionWas placed in an incubatorOther
Developmental Milestones
Would you consider the child as having been “late” in any of the following areas?

Lifting headSitting upStanding aloneWalkingMaking speech noisesTalking
At present, the child is self-sufficient for:

FeedingToilet careDressingBathing
The child is right or left handed:

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

YesNo
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?

YesNo
If yes, please state the problem and treatment
Has the child had any evidence of eye/vision problems?

YesNo
If yes, please state the problem and treatment
In addition to those previously mentioned, has the child been hospitalized for illness or surgery?

YesNo
If yes, please explain
Has the child experienced any changes in behavior as a result of illness or injury?

YesNo
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.?

YesNo
Problem blanks
Date of onset blank
Severity of condition Type a label
Treatment Type a label
Is the child presently under medication?

YesNo
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.)

YesNo
If yes, please state illness and date(s):
Has the child had a severe injury/ (Broken bones; head injury, etc.)?

YesNo
If yes, please state date and nature of injury
Did the child lose consciousness?

YesNo
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 anyBetter than averageAverageWorse than average
How easily does the child make friends?

Doesn't have anyBetter than averageAverageWorse than average
How does the child get along with teachers and others?

Easier than averageAverageWorse than averageUnsure
What strategies have been implemented to address these problems (Check which have been successful)

Verbal reprimandsTime out(isolation)Removal of privilegesRewardsPhysical punishmentAcquiescence to childAvoidance 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 timeSome of the timeNone of the time
Diagnostic Criteria
Which of the following are considered to be significant problems at the present time?

FidgetsDifficulty remaining seatedEasily distractedOften blurts out answers to questions before they have been completedDifficulty following instructionsDifficulty sustaining attentionShifts from one activity to anotherDifficulty playing quietlyOften talks excessivelyOften interrupts or intrudes on othersOften does not listenOften loses thingsOften engages in physically dangerous activities
Which of the following are considered to be a significant problem at the present time?

Often loses temperOften argues with adultsOften actively defies or refuses adult requests or rulesOften deliberately does things that annoy other peopleOften blames others for own mistakesIs often touchy or easily annoyed by othersIs 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 figureUnrealistic and persistent worry that a calamitous event will separate the child from attachment figurePersistent refusal to sleep alonePersistent avoidance of being aloneRepeated nightmares re: separationSomatic complaintsExcessive 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 eventsunrealistic concern about appropriateness of past behaviormarked self-consciousnessexcessive need for reassurancemarked 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 dayDiminished pleasure in activities;Decrease or increase in appetite assoc. with possible failure to make weight gainInsomnia or hypersomnia nearly every dayPsychomotor agitation or retardationFatigue or loss of energyFeelings of worthlessness or excessive inappropriate guiltDiminished 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 yearPoor appetite or overeatingLow self-esteemPoor concentration or difficult making decisionsFeelings of hopelessnessNever without symptoms for > 2 months over a 1-year period
Has the child exhibited any symptoms of:

Excessive lability w/o reference to the environmentExplosive temper with minimal provocationExcessive clinging, attachment, or dependence on adultsUnusual fearsStrange aversionsPanic attacksExcessively constricted or bland affectSituationally 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