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

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