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

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~ KAISERPERMANENTE" ------------ 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? . - o No DYes o Unknown w_______.._ 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 --------------.-----.-.--..------.---.- 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 -_.~- ..--- -.--------------------.-.---. w ~__.___ -..-.----..---------- Child Intake 11.2009.sgc 2
;~ KAISERPERMANENTE.. Medical HistoD: IMPRINT AREA Does the child/teenhaveanysignificantmedicallhealthproblems(e.g.asthma,diabetes,heart condition,troublewithvision,hearingor motorcontrol?) 0 No 0 Yes(pleaseexplain) ------ 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
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