PMC Child / Adolescent History

Medical History
Immunizations

Current / On-TimeCurrent / Adjusted ScheduleDelayed
Please provide answers below for any relevant medical history, or leave blank if a section does not apply.
Current medical diagnoses, if any (common conditions include asthma, allergies, eczema, diabetes):
Past medical diasnoses:
Surgeries / hospitalizations:
Genetic conditions / congenital issues:
Concussion / head injury
Seizures
Appetite / eating concerns:
Hearing or vision concerns:
Sleep concerns
Sensory processing concerns:
Other medical?

Strengths / Social / Leisure
Patient's attributes / strengths:
Hobbies / sports / participation in activities:
Interests:
Social skills:

ConcernsNo Concerns
Is patient interested in friends?

YesNo
Has the patient ever been interested in friends?

YesNo
Please briefly share about the patient's social interactions:
LEGAL
Is there any history of legal involvement (court dealings, charges, need to call/involve authorities for any reason)? If yes, please explain:

Other Information
This document is used to collect vital information in preparation for the parent interview. There may be greater detail or additional information that you would like to share and this will be discussed in-depth. You are welcome to provide additional documents during or before the visit. To make the most of the parent interview, please bring copies of (or send ahead of time) important documents such as previous evaluations, IEPs, medical records, etc.
Is there anything we did not ask about that you want to share on this form?
Please visit our website for additional information that you may find useful to help prepare for the parent interview and the rest of the assessment process. https://hrapsychservices.com/pmc
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