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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Ak.<br />
F'~ KAISERPERMANENTECJ<br />
Psychosocial History (cont'd)<br />
IMPRINT AREA<br />
~~ ~ - '--~-' ' "---' ' ' " '------..----<br />
Which of the following are currently considered to be significant problems? NONE D<br />
D Vocal tics D Motor tics D Hearing or seeing things that others cannot<br />
At what age did these problems begin? ---..-----.-.----.-------------------.--- ---.---.-----..----.-<br />
Please check if the child/teen has ever displayed any of the following behaviors: NONE D<br />
D Mannerisms are repetitive and lack function D Reacts excessively to noise<br />
D Lack of interest in other children D Does not point to or share interest with others<br />
D Overreacts to changes in routine D Overreacts to touch<br />
D Little or no attempt to communicate D Abnormal social behavior<br />
D Poor eye contact D Teacher reports social problems<br />
D Abnormal speech D Extremely restricted interest or activities<br />
At what age did these problems begin?<br />
..------..------------------------.--..---.-------------.-----------.------..---------<br />
Please check if the child/teen has ever displayed any of the following behaviors: NONE D<br />
D Excessive mood swings without reason D Self-mutilation or self-cutting<br />
D fuappropriate emotions D Graphically violent nightmares<br />
D Explosive temper D Disturbed sleep<br />
D Aggressive behavior D Racing thoughts<br />
At what age did these problems begin?<br />
..-----.--.---------------.-------------------------.--.----...-.--------------..------.---.-.-----..<br />
Please check if the child/teen has ever displayed any of the following behaviors: NONE D<br />
D Refuses to maintain weight for age and height D futense fear of becoming fat or gaining weight<br />
D Frequently complains about a body part or about D Self-induced vomiting, laxatives, diuretics or<br />
being fat enemas to prevent weight gain<br />
D Period has become irregular or has stopped D Under- or overweight for height and age<br />
D Distorted view of body D Exercises more than once a day for several hours<br />
D Restricts food intake, even if hungry D Binge eats<br />
Additional behavior related to weightlbody image: -------<br />
At what age did these problems begin?<br />
Was your child/teen exposed to an event in which he or she experienced actual or perceived threat of death or<br />
serious injury to self or others: . D No DYes<br />
If yes, which of the following describe your child since the event:<br />
D futense fear, helplessness, or disorganized or agitated behavior<br />
D Avoids activities, places, people, thoughts or feelings associated with the event<br />
o Has recurring memories of the event or repeats themes of the event in play<br />
o Seems unable to recall an important aspect of the event<br />
o Recurring distressing dreams and/or difficulty sleeping<br />
D Reduced interest or participation in significant activities<br />
D Acts or feels as if the event were being relived or reenacted (may include flashbacks)<br />
D Detached or alienated from others D Shows less emotion since the event<br />
D Shows intense distress at reminder of the event 0 Difficulty concentrating<br />
g_!!ritabi!~!Y.~routb~~t of anger _ D Easily startle~_____.___ ----<br />
Other symptoms not mentioned above:<br />
<strong>Child</strong> <strong>Intake</strong> 11.2009.sgc 6