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

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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?
.-.---­
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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