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

~ KAISERPERMANENTE..
Psychosocial Histor
Current GPA
IMPRINT AREA
~_, M___________________.._________.._.____...____
--------.------..---..----------.------.--.--.-- ---------.---.----.--.--.----.......---.--...--.­
Does your child/teen have any Learning Disabilities?
o No 0 Yes
.--.------.------.-----.---------------.--.--..---..------. -------......-.---.------­
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)
~ , "._-_....-----.--­
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
W_M ~
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
w M_____.___...._.___..__._..___
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_._..___.___
----- ---.-- ------------.----.--.-----­
-- --. --.------.----.-.­
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#
-----------...--­
------- ---- --------
----------- -------------- ---------
------.­ .-.--.--.-------------
-- --------
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