Victoria Martin, M.D.
New Patient Enrollment - Children & Adolescents
Patient's Name
*
First Name
Middle Name
Last Name
Suffix
Date of Birth
*
Birth Sex
Please Select
Female
Male
Intersex
Prefer not to respond
Contact Number:
*
Secondary Number:
E-mail
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list all parents and/or legal guardians and their contact information:
In case of emergency
Emergency Contact:
First Name
Last Name
Relationship
Contact Number
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Developmental and Social History
Children & Adolescents
What is the patient's current age?
Pregnancy was:
Please Select
Full Term
Premature
Late
Unknown
Child's delivery was:
Please Select
Normal
Caesarian
Breech
Forceps
List any complications with pregnancy or delivery:
List age (in months) when achieved the following developmental milestones:
First word:
First walked alone:
Bladder/Bowel training complete:
Note any difficulties with bladder or bowel control:
Has the patient ever been adopted?
Yes
No
Give details:
Where was the patient born?
Where has the patient been raised?
Describe how the patient gets along with parents:
List names and ages of everyone who lives at home (current main residence) and their relationship to the patient:
Are parents divorced?
Yes
No
How old was the patient?
Does the child stay with one parent more than the other?
Yes
No
Which parent?
Where does the other parent live?
How much time is spent with that parent?
List names and ages of everyone who lives in that parent's home and their relationship to the patient.
Has anyone in the patient's immediate family died?
Yes
No
Who and when?
Has the patient ever been physically or sexually abused?
Yes
No
At what age(s)?
By whom?
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Academic and Behavioral History
Children & Adolescents
Does the patient enjoy school?
Current grade:
Please Select
Pre-K
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
School name:
Describe any academic or disciplinary problems at school:
Describe any recent changes in school performance:
Has the patient ever had to repeat a grade?
Yes
No
Describe the circumstances:
Describe any extracurricular activities:
Describe relationships with peers at school:
List any legal charges, probations or arrests:
Has the patient ever experimented with tobacco, alcohol or drugs?
Yes
No
Please elaborate:
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Medical History
Children & Adolescents
Who is the patient's primary care physician?
When was the patient's last appointment?
Does the patient have any ongoing medical conditions?
Yes
No
Please list any medical conditions:
Has the patient ever had surgery?
Yes
No
Please list any previous surgeries:
Has the patient ever experienced any heart problems?
Yes
No
Explain any previous/current heart problems:
Is there any possibility that the patient is pregnant?
Yes
No
Is the patient considering pregnancy?
Yes
No
Has the patient ever seen a psychiatrist?
Yes
No
Please list the patient's previous psychiatrist(s) and dates seen:
Describe the treatment:
Has the patient ever seen a therapist?
Yes
No
Please list any current/previous therapists and dates seen:
Has the patient ever been hospitalized for a psychiatric episode?
Yes
No
Please describe the circumstances of the hospitalization(s) and dates of admission:
Is the patient taking any medications or vitamins, currently?
Yes
No
List all medications and vitamins with dosing:
Has the patient ever previously been prescribed medication? (not currently taking)
Yes
No
List all medications previously prescribed:
Is the patient allergic to any medications?
Yes
No
List all medications the patient is allergic to:
List any blood-relatives that have had a history of psychiatric or emotional problems:
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Mood Disorders
Children & Adolescents
For each of the following statements, select 1 of the 4 responses that best fits the patient. (All statements must be answered)
*
None
Little
Moderate
Severe
I have had a depressed mood most of the time.
I have experienced unusually irritable moods, by subjective opinion or by report of others.
I have experienced loss, or diminished interest or pleasure in
activities.
I sometimes suffer from insomnia. (Can’t sleep)
I sometimes suffer from hypersomnia. (Can’t stay awake)
I suffer from fatigue or memory loss.
I have feelings of worthlessness.
I have feelings of guilt.
I have difficulty thinking.
I have recurrent thoughts of death.
I believe that I have had suicidal thoughts.
I have, or have had a plan for suicide.
I have been troubled by a distinct period of abnormally elevated or expansive mood.
At distinct periods of time, I have inflated self-esteem or grandiosity, (Belief that you have super-natural talents, powers, or that you are going to be famous or do great things).
At distinct periods of time, I am more talkative than usual or feel pressure to keep talking.
Sometimes I feel that my thoughts are racing.
I have experienced a marked increase in activity or psychomotor agitations (tapping foot or hand).
I participate to excess in pleasurable activities that have great potential for painful consequences.
Additional notes:
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ADHD Rating Scale
Children & Adolescents
For each of the following statements, mark the box under "YES", "SOME" or "NO" depending upon which best fits the patient. (All statements must be answered)
*
Yes
Some
No
I fail to pay close attention to details or I tend to make careless mistakes.
I have difficulty sustaining attention.
I often find I have failed to listen or have read a paragraph and don't know what I have read.
I have difficulty finishing tasks, or I have multiple projects going at the same time.
I have difficulty organizing tasks and activities.
I often misplace or lose items.
I am easily distracted by extraneous stimuli.
I often seem forgetful or absent-minded, even regarding daily activities.
I often fidget with my hands and feet.
I feel "on the go" as if I am driven by a motor.
I interrupt conversation or blurt out answers before questions have been completed.
I am impatient and I have trouble waiting.
I feel that I have failed to accomplish what I'm capable of.
I procrastinate (put things off).
I am a risk taker.
I get bored easily.
I have a history of impulsive behavior.
I have frequent and dramatic mood swings.
I have difficulty settling down at night and going to sleep.
I struggle with low self-esteem.
Additional notes:
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Anxiety Rating Scale
All Ages
For each of the following statements, select 1 of the 4 responses that best fits the patient. (All statements must be answered)
*
None
Little
Moderate
Severe
I have experienced palpitations, pounding heart or accelerated
heart rate.
I have experienced excessive sweating.
I have experienced trembling or shaking.
I have experienced sensations of shortness of breath or
smothering.
I have experienced a sensation of choking.
I have experienced chest pain or discomfort.
I have experienced nausea or abdominal distress.
I have felt dizzy, unsteady, lightheaded or faint.
I have experienced feelings of unreality or depersonalization
(feeling detached).
I have experienced fear of losing control or going crazy.
I have experienced fear of dying.
I have experienced numbness and/or tingling.
I have experienced chills or hot flashes.
I have experienced fear about being in places or situations
where escape might be difficult or embarrassing.
I have experienced recurrent and persistent thoughts that are
interpreted as intrusive and inappropriate, that cause marked
stress, and that are not simply excessive worries about real
life problems.
I engage in repetitive behaviors (e.g. hand washing, rechecking) or repetitive thoughts (e.g. counting, repeating
words) aimed at reducing stress, which is not connected in a
realistic way to the stress, which I aimed at reducing.
The behaviors mentioned in the above two questions are
stress producing or time consuming (taking more than one
hour per day) or interfere with my normal routine, occupation,
or social activities.
I have suffered from excessive anxiety more days than not for
at least 6 months about a number of events or activities.
I find it difficult to control anxiety.
I suffer from anxiety associated with restlessness, being easily tired, difficulty concentrating, irritability, muscle tension or sleep disturbance.
Anxiety interferes with my normal routine, occupation, or
social activities.
Additional notes:
Submit
Should be Empty: