Pre-Evaluation Questionnaire Child

Pediatric Pre-Evaluation Questionnaire
Please provide the name and relationship of the individual completing the form.
Reporting Individual's Name*

First NameLast Name
Relationship to the child*
Phone Number*

Area CodePhone Number
INSTRUCTIONS FOR COMPLETING

Please answer the following questions about your child's health and history. Although this form is lengthy, it is designed to be very thorough. Completing this information before your appointment will greatly assist the doctor to best use your assessment time with her/him by enabling a more detailed focus.
Demographics
Child's Name*

First NameMiddle NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Sex*
Child's Handedness (if known)*
Child's Ethnicity*
Child's Pediatrician*
Doctor's Name
Pediatrician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pediatrician's Phone Number*

Area CodePhone Number
Pediatrician's Fax Number

Area CodePhone Number
May we contact your child's doctor?*

YesNo
Referral Information
Who referred you for this evaluation?*
If referred by a specific physician, mental health care provider, or other specialist, please provide his/her name, specialty, and contact information below:
Name of referral*
Specialty
Address of referral

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Referral's Phone Number*

Area CodePhone Number
Referral's Fax Number

Area CodePhone Number
May we contact the provider that referred you?*

YesNo

Presenting Problem
Please describe what concerns you have with your child's behaviors or development. Also describe how long your child has been experiencing these problems and a brief description of the course*
Did these changes have an abrupt or gradual onset?*

AbruptGradual
Please describe any social/family/emotional stress and/or environmental changes that occurred around the time of onset?

	Yes	No	How long?
Does your child nap during the day?

	Name of school	Grade	Teacher's name
The child's current school.

	Not at all	A little	Somewhat	Mostly	All the time
Colic and irritable
Feeding problems
Sleeping problems
Restless
Overactive
Does not enjoy cuddling
Tantrums and/or head banging
Accident prone and/or daredevil
Uncoordinated
Avoids eye contact
Dislikes contact with people

	Yes	No	What age and treatment
Sucks thumb
Grinds teeth
Bites nails
Picks skin
Tics/twitches
Rocks back and forth
Unusual body movements
Bangs head
Physically hits self
Physically hits others
Lies
Steals or hides other's things
Hoards
Chronically overeating to the point of getting sick
Purposefully vomiting
Restricting food intake
Cuts self
Threaten to kill his or herself

	Mother	Father
Age
Highest level of education complete
Degrees/diplomas
Current occupation.
Describe any special education or tutoring received.
Describe grades repeated or subject areas that were difficult.
Any diagnosed learning difficulties? If so, in what subjects?
Any psychological or psychiatric problems for which treatment was received?
Any diagnosis of attention deficit disorder (with or without hyperactivity)?

	Maternal (mother's side)	Paternal (father's side)	Relationship
Attention deficit disorder
Learning difficulties
Behavioral problems
Seizures/epilepsy
Migraines
Alcoholism/drug abuse
Depression
Anxiety
Bipolar disorder
Schizophrenia
Autism
Other developmental disability
Congenital abnormalities
Other neurological conditions

	Yes	No	Please describe
Does the child have a consistent bedtime routine?
Are you concerned that the child does not get enough sleep and/or has poor sleep quality?

	Yes	No	Please explain
Does the child have difficulty relating to other children?
Does the child physically fight with other children?
Does the child argue with other children?
Does the child prefer playing with younger children?
Does the child prefer playing with older children or adults?
Does the child have difficulty making friends?
Does the child have difficulty maintaining friendships?
Does the child have a best friend?
Is the child invited to other children's houses for play dates?
Is the child invited to birthday parties as often as you think he/she should be?
Are there children in your neighborhood with whom the child can play?
Does the child prefer to play alone?
Does the child have difficulty with the nonverbal rules of social interaction (e.g., turn taking, how close to stand to others).

	Yes	No	What age and treatment
Measles
German measles
Mumps
Chicken pox
Tuberculosis
Rheumatic fever
Diphtheria
Meningitis
Encephalitis
Whooping cough
Scarlet fever
Sustained high fever
Any fever above 104 degrees
Anemia
Allergies to food
Environment allergies
Uses hearing aid
Wears glasses/contact lenses

	Yes	No	What age and treatment
Frequent colds
Chronic cough
Asthma
Hay fever
Sinus condition
Chronic sinus infection
Sleep apnea
Other respiratory conditions

	Yes	No	What age and treatment
Shortness of breath with exertion
Dizziness with exertion
Heart condition
Heart condition
Heart murmur
Blood clots
Other cardiovascular conditions

	Yes	No	What age and treatment
Excessive vomiting
Frequent diarrhea
Constipation
Stomach pain
Heartburn/acid reflux
Other gastrointestinal conditions

	Yes	No	What age and treatment
Muscle pain
Clumsy walk
Poor posture
Scoliosis
Broken bones
Other musculoskeletal conditions

	Yes	No	What age and treatment
Seizures
Brain injury/concussion
Stroke
Brain tumor
Abrupt mental status change
Spinal cord injury
Other neurological condition

	Names of preschool/day care/school	Grade	From (date)	To (date)	# day a week	# hours a day
1
2
3
4
5

	Name of medication (e.g., Tylenol)	Strength (Dose) (e.g., 500 mg)	How often per day (e.g., 1 pill 3 times a day)
1
2
3
4
5

Pediatric Pre-Evaluation Questionnaire