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