Child English Intake - My Doctor Online The Permanente Medical ...

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t\l~ KAISERPERMANENTE,
Child, Adolescent and Family Intake
IMPRINT AREA
To be completed by parent or legal guardian ~ r
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i GENDER I
I CHILDITEEN'S NAME _I MEDICALREC~~D#
ICITY/COUNTRY OF ORIGIN
IPEDIATRICIAN i BIRTHDATE IETHN
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IADDRESS(STREET)
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IHOME PHONE
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CITY ZIP CODE (TEEN) CELL PHONE i i
NAME OF PERSON COMPLETING FORM LEGAL GUARDIAN? , RELATIONSHIP RELIGION
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SCHOOL(NAME) SCHOOLCOUNSELOR SCHOOLGRADE I
MOTHER'S NAME / LEGALGUARDIAN HOMEPHONE WORK PHONE CELL PHONE
OCCUPATION: AGE YEARS OF SCHOOL
FATHER'S NAME / LEGALGURADIAN HOME PHONE WORK PHONE !CELL PHONE
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OCCUP ATlON: AGE YEARS OF SCHOOL
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IF DIVORCED,WHOHASLEGALCUSTODY?
CHECK 0 0 0 0
ONE: MARRIED DIVORCED SEPARATED UNMARRIED YEAR DIVORCE WAS FINALIZED?
NAMES OF OTHER CHILDREN/TEENS OR ADULTS IN THE HOME
NAME
NAME
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RELATIONSHIPTO CHILD/TEEN.(BIO SIBLING, I
I AGE STEPSILING, ETC.)_ -..-.J
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What to you wish to get from today's visit?
Current Concerns
What is the mainreasonfor comingin today?(checkall that apply)
o ParentsDivorced/Separated 0 FamilyIllness o Deathin Family
o Parent ChangedJobs 0 ChangedSchools o FamilyMoved
o ParentalConflict 0 FinancialProblems o Significantdrop in grades
o LegalProblems 0 Threatsof suicideor homicide o Schoolrefusal
o Drug!Alcohol Use o Violence at home
o RecentPsychiatricHospitalization 0 Other
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Prenatal and Birth
Was your child adopted? 0 Yes 0 No If Yes, at what age?
IMPRINT AREA
How wasthe biologicalmother's healthduringpregnancy? 0 Good 0 Fair 0 Poor 0 N/A
How old was the biological mother when the child was born? o Unknown
Did the motheruse any of the followingsubstancesor medicationwhilepregnant?
o Alcohol 0 SleepingPills 0 Heroin 0 DiabetesMedication
o Tranquilizers 0 Marijuana 0 Methamphetamine 0 Cigarettes
o Antibiotics 0 Cocaine 0 Anti-SeizureMedication
Other:
Did toxemiaor eclampsiaoccurat birth? 0 No 0 Yes 0 Unknown
The childwasborn: 0 Before8 months 0 Atterm (8-10months) 0 10months 0 Unknown
Werethereany complicationsduringlabor?0 No 0 Yes (pleaseexplain) 0 Unknown
~M_'_' " ' '__' '_M_________________________________________.___._______...___._____..___.____..___._..__.._......__.....
Did the child experience any of the following during delivery? (Check all that apply)
o Normal 0 Caesarian 0 Breech 0 Forceps 0 Induced 0 FetalDistress 0 Unknown
Werethereany healthcomplicationsfollowingbirth? 0 No 0 Yes(pleaseexplain)? 0 Unknown
M._._.___._________________________ --.--.------.-.-.---------------.---.---.--­
-------.--.--.-.---.----.----.-.--------------.--.---.-------.---------.----.-.-.-.-.-------....---
Infancv and Development
Were there early infancy feeding problems? o No DYes o Unknown
.Was the child colicky (difficult to soothe, cried a lot)? o No DYes o Unknown
Were there infancy sleep pattern difficulties? o No DYes o Unknown
Were there problems with the infant's alertness?
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o No DYes o Unknown
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How easy was it to get the child calm and on a schedule? (check one)
. 0 YetyJ~.~~Y 0 Ea~y" 0 Av~~
How sociable was the child with other people? (check one)
_!;JV efY-_~oc!a~!.t? P Ay-erag~_s()ciability ------.---.--..---.-------­
o Less sociable
What was the child's activity level as an infantltoddler:(check one)
Very active Active
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ODD
Less active
Where there any delays in developmental milestones, such as sitting up, crawling, walking, talking or toilet
training? 0 No 0 Yes (please explain) 0 Unknown
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Child Intake 11.2009.sgc 2

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Medical HistoD:
IMPRINT AREA
Does the child/teenhaveanysignificantmedicallhealthproblems(e.g.asthma,diabetes,heart
condition,troublewithvision,hearingor motorcontrol?) 0 No 0 Yes(pleaseexplain)
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Pleasecheckif the child/teenhadanyof the following:
o Mumps 0 Pneumonia 0 WhoopingCough
o ScarletFever 0 Seizures 0 Multipleear
infections
o LeadPoisoning 0 ChickenPox Other
Hasthe child/teenhad anyaccidentsresultingin the following:
o Encephalitis
o Measles
o BrokenBones
o LostTeeth
0 Head Injury
0 SevereBruises
0 Eye Injury
0 Sutures
o Severe Lacerations
Other_
Is therea historyof 0 0 0 0
o o
abuse? Physical Sexual Emotional Neglect Unknown None
If yes,pleaseexplain:
Has there ever been any type of contact with Child Protective Services? 0 No 0 Yes (please
explain)
If your child has experienced a head injury, did-they lose consciousness? 0 Nohowlong?
0 Yes If yes,for
Does the child/teen currently have any sleep problems? 0 None
o 0 0 o o
Difficulty Earlymorning Restlesssleep Difficultystaying Oversleeping
fallingasleep awakeni.!!g asle~
Doesthe child/teenhavedifficultywithbladder/bowelcontrol?
o Unknown Current: 0 No 0 Yes Past: 0 No 0 Yes
--The-chiidJteen;s-appetite is:---" OL;rg~-D-Average "---"-ErsmaIler than"average ­
than average _
Hasthe child/teeneverbeenprescribedmedicationssuchas: Ritalin,Dexedrine,Anticonvulsants,or
Antihistamines? 0 No 0 Yes 0 Unknown
Is the child/teencurrentlyon anymedications? 0 No 0 Yes(pleaselist)
Psychosocial History
Pleasecheckone that describesthe child/teen'sSOCIALSKILLSwithinthe followinggrades:
Preschool: 0 Poor 0 Average 0 Good 0 Unknown
Kindergarten: 0 Poor 0 Average 0 Good 0 Unknown
Grades 1-3: 0 Poor 0 Average 0 Good 0 Unknown
Grades4-6: 0 Poor 0 Average 0 Good 0 Unknown
Grades 7-12: 0 Poor 0 Average 0 Good 0 Unknown
Pleasecheckone that describesthe child/teen'sPROFECIENCYTESTINGwithinthe followinggrades:
Preschool: 0 Poor 0 Average 0 Good 0 Unknown
Kindergarten: 0 Poor 0 Average 0 Good 0 Unknown
Grades 1-3: 0 Poor 0 Average 0 Good 0 Unknown
Grades4-6: 0 Poor 0 Average 0 Good 0 Unknown
Grades 7-12: 0 Poor 0 Average 0 Good 0 Unknown

~ KAISERPERMANENTE..
Psychosocial Histor
Current GPA
IMPRINT AREA
~_, M___________________.._________.._.____...____
--------.------..---..----------.------.--.--.-- ---------.---.----.--.--.----.......---.--...--.­
Does your child/teen have any Learning Disabilities?
o No 0 Yes
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Does your child have an IEP (Individual Education Plan)? 0 No 0 Yes (Checkall thatapplybelow)
o Learningdisabilityclass 0 SpeechTherapy 0 LanguageTherapy 0 ResourceRoom
o Behavioralor EmotionalDisorders Other: .--------- ------..-....--.-...--­
-------.-----. .-------------------....-...
Has the child/teeneverbeen suspended,expelledor retainedin grade? 0 No 0 Yes(pleaseexplain)
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Has the child had contact with the Juvenile Justice System? Y / N If yes, please explain
How does the child/teen get along with siblings?
o Better than average 0 Average o Worse than average o No Siblings
M__..___._____...___________.____.__.____._____..___.________._____.____.________..._____.__.__
How easily does the child make friends?
_.P E~sier!!Ian avera~~ 0 Average ~Wo.!:~~ th~_averag.~_____.___._._._____._.__...___.____.________._
_Ar~ there any ~s in the home(s) in_~hichyo~..£hild ~tays~ Y / N _______._______________.____._.___.______.___
What strategies have you used to address behavior concerns/problems?
o Verbal reprimands/discussion 0 Times out 0 Removal of privileges 0 Rewards
o Physical punishment 0 Avoid child 0 Give in to child Other
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To what extent are you and your spouse/partner consistent with discipline?
o Most ofthe time 0 Some of the time 0 None of the time
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How stable is your relationship with your current partner?
OVery stable 0 Average 0 Less stable than average 0 No current partner
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My child/teen has been psychiatrically hospitalized at (name(s) of hospital/facility). 0 None
When? Where?
M_________ ---------. M_._..___.___
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Has the child/teen ever received any forms of psychotherapy? 0 No
o Individual 0 Family 0 Inpatient 0 Residential (overnight) Other
List the doctor(s) and/or therapist(s) information
Name Address Phone#
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Listedbeloware several ou s of roblems leasecheckallthat a I. If our child/teenDOESNOT have
in a particulararea,pleaseindicateNONE ~.
Whichof the followingare currentlyconsideredto be significantproblems? NONE 0
o Blurtingoutanswersto questions 0 Fidgeting
o Difficultyawaitingturn 0 Oftendoesnot listen
o Difficultyfollowinginstructions 0 Oftenengagesin dangerousactivities
o Difficultyplayingquietly 0 Ofteninterruptsothers
o Difficultyremainedseated 0 Oftenlosesthings
[j Difficultysustainingattention
o Easily distracted
o Easilybored
At ~~a~agedi

. IMPRINT AREA
r';KAISERPERMANENTE.
Psychosocial History (cont'd)
-Whi~h oith~ foll~i~g-;~ c~entiY-con~d~;edt~-be~i~ifi~~t pr~blems?- NONE 0------------------------o
Blames others for own mistakes 0 Often argues with adults
o Oftenangryor resentful 0 Oftendeliberatelyannoyspeople
o Oftentouchyor easilyannoyedby others 0 Oftenlosestemper
o Oftendefiesauthorityfigures' requestsor rules
At what age didtheseproblemsbegin?
Which of the following are currently considered to be significant problems? NONE 0
o Stolen without confrontation 0 Forced someone else into sexual activity
o Stolenwith confrontation 0 Deliberatelysets fires
o Breaking and entering 0 Cruel to animals
o Destroyedothers' property 0 Useda weaponin a fight
o Run away fromhomeat leasttwice 0 Ofteninitiatesphysicalfights
o Oftenlies 0 Physicalcruelto people
o Oftentruant 0 Alcohol/Druguse
At what age didtheseproblemsbegin?
Which of the followingare currentlyconsideredto be significantproblems? NONE 0
o Unrealisticworryaboutfutureevents 0 Unrealisticconcernsaboutcompetence
o Unrealisticconcernaboutpastbehavior 0 Extremeself-consciousness
o Complaints about body aches and pains 0 Excessive need for reassurance
o Inability to relax
At what age did these problems begin?
Which of the following are currently considered to be significant problems? NONE 0
o Unrealisticandpersistentworryaboutarmto familymembers
o Unrealistic and persistent worry that a terrible event will separate child from family
o Persistentschoolrefusal 0 Persistentrefusalto sleepalone
o Persistentavoidanceof beingalone 0
o Repeatednightmaresregardingseparationfromthe family
o Excessivedistressin anticipationof beingseparatedfromparent/guardian
o Excessivedistresswhenseparatedfromparent/guardian
At what age did theseproblemsbegin?
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Whichof the followingare currentlyconsideredto be significantproblems? NONE 0
o Depressed or irritable mood most of the day, nearly every day
o Decreased or increased appetite associated with weight loss or gain
o Feelingworthlessor excessiveand inappropriateguilt
o Feelinghopeless 0 LowSelf-esteem
o Sleepstoo muchor too little 0 Decreasedpleasurein activities
o Increasedfatigueor tiredness 0 Decreasedabilityto concentrate
o Increasedor decreasedenergyand movement 0 Has thoughtsof hurtingothers
o Has attemptedsuicide. 0 Has expressedthoughtsof suicide.
When? When: 0 Past 0 Current
At whatage did theseproblemsbegin?
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Psychosocial History (cont'd)
IMPRINT AREA
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Which of the following are currently considered to be significant problems? NONE D
D Vocal tics D Motor tics D Hearing or seeing things that others cannot
At what age did these problems begin? ---..-----.-.----.-------------------.--- ---.---.-----..----.-­
Please check if the child/teen has ever displayed any of the following behaviors: NONE D
D Mannerisms are repetitive and lack function D Reacts excessively to noise
D Lack of interest in other children D Does not point to or share interest with others
D Overreacts to changes in routine D Overreacts to touch
D Little or no attempt to communicate D Abnormal social behavior
D Poor eye contact D Teacher reports social problems
D Abnormal speech D Extremely restricted interest or activities
At what age did these problems begin?
..------..------------------------.--..---.-------------.-----------.------..---------­
Please check if the child/teen has ever displayed any of the following behaviors: NONE D
D Excessive mood swings without reason D Self-mutilation or self-cutting
D fuappropriate emotions D Graphically violent nightmares
D Explosive temper D Disturbed sleep
D Aggressive behavior D Racing thoughts
At what age did these problems begin?
..-----.--.---------------.-------------------------.--.----...-.--------------..------.---.-.-----..­
Please check if the child/teen has ever displayed any of the following behaviors: NONE D
D Refuses to maintain weight for age and height D futense fear of becoming fat or gaining weight
D Frequently complains about a body part or about D Self-induced vomiting, laxatives, diuretics or
being fat enemas to prevent weight gain
D Period has become irregular or has stopped D Under- or overweight for height and age
D Distorted view of body D Exercises more than once a day for several hours
D Restricts food intake, even if hungry D Binge eats
Additional behavior related to weightlbody image: -------­
At what age did these problems begin?
Was your child/teen exposed to an event in which he or she experienced actual or perceived threat of death or
serious injury to self or others: . D No DYes
If yes, which of the following describe your child since the event:
D futense fear, helplessness, or disorganized or agitated behavior
D Avoids activities, places, people, thoughts or feelings associated with the event
o Has recurring memories of the event or repeats themes of the event in play
o Seems unable to recall an important aspect of the event
o Recurring distressing dreams and/or difficulty sleeping
D Reduced interest or participation in significant activities
D Acts or feels as if the event were being relived or reenacted (may include flashbacks)
D Detached or alienated from others D Shows less emotion since the event
D Shows intense distress at reminder of the event 0 Difficulty concentrating
g_!!ritabi!~!Y.~routb~~t of anger _ D Easily startle~_____.___ ----­
Other symptoms not mentioned above:
Child Intake 11.2009.sgc 6

. IMPRINT
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AREA
Bioloe:ical Familv HistOry
Please note who, if any, of the child/teen's biological relatives have had these conditions. ("blood related" family
members only; i.e. mother, father, sibling, aunts, uncles, grandparents)
Condition
Childhood aggression, defiance
Childhoodinattention,over-activityand poor impulsecontrol .____.________._
Learningdisabilities .______._
Did not graduate high SChool.._________.___.._.______._________._._______.____..___
Developmental delays ..___________.___._._____._..____.____._.__
Schizophrenia or psychosis
Depression for more than 2 weeks
Anxiety or OCD
Tics/Tourettes
--------.----.-.--.--­
Drug abuse .. ________.___.___..__.____._____.___
.-----.-.-­
Antisocial behavior (assaults, thefts, criminal behavior, arrests )____._.._____.__._......_._.__..____.__._____.___._._...____._.._
Family history
Physicalabuse ....__.._______..____._.__.__._._______._...._.____.___._._..._________..__.._
Sexual abuse ---~_M M M M__
Neglect/emotional abuse ____.___.__..__._._.._.___..___._...
comments:
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THANK YOU FOR YOUR TIME AND ATTENTION II
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Location:
Name:
CONFIDENTIALITY DISCLOSURE IMPRINT AREA
KPNC's Mental Health and Chemical Dependency Services:Your Right to Privacy
Kaiser Permanente's Mental Health and Chemical Dependency (MH/CD) Program is strongly committed to protecting
your privacy.The Northern California Notice of Privacy provides general information about how your medical information
is used and protected. Federal and state law protects the confidentiality of chemical dependency records.Violation of
federal confidentiality laws related to chemical dependency programs is a crime. Suspected violations may be reported to
the appropriate authorities.
Except under limited circumstances (see examples below), Kaiser Permanente's MH/CD program may not, without your
written permission, disclose information about your care to anyone outside of Kaiser Permanente. For your privacy,
psychotherapy records of your MH/CD visits are kept separate from your outpatient medical record. Regardless of the type
of visit, however,for your personal safety, your medication visits, the list of medications, laboratory results, a description of
medication results, and prognosis are included in your medical record, either on paper or electronically.
Coordination of Care
At Kaiser Permanente MH/CD services staff are considered one department, the Department of Psychiatry.Therefore, any
MH/CD information can be shared between Mental Health staff and Chemical Dependency staff within the department
without your written permission. However,the regulations pertaining to disclosing information outside the Department of
Psychiatry are different for mental health patient information than for chemical dependency patient information.
Patients ReceivingOnly Mental Health Care: For mental health care, your permission is not requiredto coordinate your care
with other providerswithin Kaiser Permanente,such as your primarycare physician.MentalHealth diagnosesand appointment
dates are available to your other Kaiser Permanente treating providers on a need-to-know basis. However,ordinarily we
will discuss with you any necessary sharing of other mental health information. When we share information we only share
that information which, in our professional judgment, we believe is needed for appropriate medical care by that provider.
Patients Receiving Chemical Dependency Care: For chemical dependency care (which would include mental health care
that is part of your chemical dependency care), your written authorization is normally required before any information
about chemical dependency treatment can be disclosed to anyone outside the Department of Psychiatry. For your safety
and effective coordination of your health care, we strongly believe it is important for us to share information about your
chemical dependency treatment with your other Kaiser Permanente treating providers. In order for us to do that, you must
sign a written authorization to allow us to share your chemical dependency patient information with them.
Exceptions to Confidentiality Rules
Sometimes the law authorizes us to disclose information about you without your permission, such as disclosures:
· in medical and psychiatric emergencies in which the information is essential to an individual's safety
· to warn potential victims of violent acts
· to qualified personnel for audit, program evaluation, or research;for example, patient surveys
· for reporting of suspected child abuse or neglect
· to report the commission of crimes on our premises or against our program personnel
· in response to court orders that comply with the standards for the type of record covered by the order
· in reports to the Department of Motor Vehicles due to lapses of consciousness as required by law
If at any time you have concerns about your privacy,you are encouraged to request clarification from your therapist or a
staff member.
Acknowledgment:
By signing your name in the space below, you acknowledge that you have read and understood this document.
(Note: If the person receiving care is a minor, then a parent or legal guardian acknowledges having read and understood this
document. Under certain circumstances, minors may consent to treatment themselves without parental permission.)
SIGNED: PATIENT'SOR REPRESENTATIVE'S DATED SIGNATURE
PRINT NAME AND RELATIONSHIPTO PATIENT(IF SIGNED BY AUTHORIZED REPRESENTATIVEOFTHE PATIENT)
02150-005 (REV. 5-07) FOR SPANISH USE -006
DATE
DATE
DISTRIBUTION: WHITE = PSYCHIATRY FILE. CANARY = PATIENTCOPY

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PERMANENTE~
CONFIDENTIALITY AND CONSENT TO TREATMENT IMPRINT AREA
~Iental Health and Chemical Dependency
Your Kaiser Permanente Psychiatry Department is strongly committed to your right to privacy.Toward thie;
end, records related to your visits in the Psychiatry Clinic are generally kept separate from your medical record.
However, for your safety, any medications you may be prescribed in the Psychiatry Clinic are noted in your
medical chart. Information might be exchanged between a Kaiser Permanente mental health provider and
another Kaiser Pennanente provider when the information is pertinent to the direct clinical care of the individual.
Also, there are some specific circumstances when California law requires the release of certain psychiatric
information. For example, if you are involved in certain legal actions in which your emoti9nal or mental state is
an issue, we may be required by law to release infonnation from your psychiatric records to parties involved in
that legal action. Any time you are asked to sign a release of information,.,talkto your therapist if you have any
concerns about what is in your record.
In addition, we may be required to report, to police or other governmental agencies, certain infonnation
that relates to either actual or potential violent or abusive acts of which we might become aware.
Consent to Treatment
Most people who participate in behavioral or mental health treatment benefit from it. Like most kinds of
health care, this kind of treatment requires a very active effort on your part if you are going to get something out
of it. In addition, there may be certain kinds of risks involved. For example, the therapy process can be challenging
and sometimes may involve experiencing some uncomfortable feelings, or engaging in difficult interactions,
or facing difficult aspects of your life. Nevertheless, most people find the benefits outweigh any such
risks. In fact, sometimes there can be more risks associated with not participating in therapy.
If you ~ee a physician as part of your care, he or she may prescribe medication for you. If so, you'll be
advised at that time of the benefits and any risks of the medications.
It is important that you participate in this treatment willingly. If you have any questions or concerns about
this document, about the services being provided to you, or about your treatment options, you should definitely
ask your therapist.
Acknowledgment
By signing your name in the space below, you are acknowledging that you have read and understood this
document and that you voluntarily agree to participate in this treatment. If the persoll receiving care is a minor;
a parent or legal guardian acknoH;ledgeshaving read and understood this document and voluntarily agrees to
the minor's participation in the treatment (except in certail1legally exempt situations).
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PATIENT'S:;;GN~TURE(IFS;GNATUPEOTHER T"'A~PATIENT.lIST RELATIONSHIP) ;OATE
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