Today's Date *

MM

DD

YYYY

Patient's Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

1st Parent's/Guardian's Name *

First Name

Last Name

Mobile Phone Number *

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

2nd Parent/ Guardian's Name

First Name

Last Name

Mobile Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Has the child ever been evaluated or received any of the following services before?

Early Intervention

Physical Therapy

Speech and Language

Occupational Therapy

Psychological/Psychoeducational

Applied Behavior Analysis

Other

Has this child experienced any of the following problems?

Walking difficulty

Underweight/ overweight problem

Colic

Sleep problem

Eating disorder

Was this child breast-fed? *

Yes

No

Was this child bottle-fed? *

Yes

No

Has child received speech-language therapy? *

Yes

No

Has the child had the following immunizations?

Measles

Mumps

DPT

Polio (OPV)

Tetanus

Has any blood relation (Parent, Sibling, other) had:

Tuberculosis

Syphilis

Diabetes

Cancer

Kidney Trouble

Heart Trouble

Stomach Trouble

Rheumatism (Arthritis)

Asthma, Hay Fever, Hives

Epilepsy (Fits)

Died by Suicide

Child is: *

Natural

Adopted

Foster

Mother's Name *

First Name

Last Name

Mother's D.O.B. *

MM

DD

YYYY

Father's Name *

First Name

Last Name

Father's D.O.B. *

MM

DD

YYYY

Does your child experience any difficulties in the following areas?

MOOD

Sadness

Tearfulness

Irritability

Sleep Problems

Weight Change

Loss of Interest/Pleasure in activities

Increased/Decreased Talkativeness

Increased/Decreased Activity

Increased Mood

Negative Thoughts about Self

Does your child experience any difficulties in the following areas?

ANXIETY

Worry

Fears

Repetitive Behavior

Headaches

Stomachaches

School Absenses

Recurring thoughts

Panic Attacks

Increased Startle Response

Nightmares

Does your child experience any difficulties in the following areas?

ATTENTION / CONCENTRATION:

Inattention

Careless Mistakes

Impulsive

Fidgety

Distractible

Acting Out

Loses Things

Difficulty Organizing

Difficulty Completing Tasks

Does your child experience any difficulties in the following areas?

BEHAVIOR

Fighting

Cruelty to Animals

Aggressiveness

Non-Compliance

Lying

Swearing

Temper Tantrums

Does your child experience any difficulties in the following areas?

SOCIAL / COMMUNICATION / INTERPERSONAL

Difficulty making friends

Unaware of social rules

Poor eye contact

Preference for routines

Intense Interests

Repetitive Motor Behaviors

Disinterest in sharing experiences with Others

Limited make-believe/spontaneous Play

Difficulty initiating/sustaining conversations

Any history of exposure to physical, sexual, or emotional abuse? *

Yes

No

Any exposure to domestic violence? *

Yes

No

School's Phone *

(###)

###

####

Did the child attend day care? *

Yes

No

How was the child's Social Adjustment?

Good

Fair

Poor

Did child experience separation problems?

Yes

No

Has your child ever had or currently has an Individualized Education Plan (IEP)? *

Yes

No