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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. IMPRINT<br />
, ,t; KAISERPERMANENTE"<br />
AREA<br />
Bioloe:ical Familv HistOry<br />
Please note who, if any, of the child/teen's biological relatives have had these conditions. ("blood related" family<br />
members only; i.e. mother, father, sibling, aunts, uncles, grandparents)<br />
Condition<br />
<strong>Child</strong>hood aggression, defiance<br />
<strong>Child</strong>hoodinattention,over-activityand poor impulsecontrol .____.________._<br />
Learningdisabilities .______._<br />
Did not graduate high SChool.._________.___.._.______._________._._______.____..___<br />
Developmental delays ..___________.___._._____._..____.____._.__<br />
Schizophrenia or psychosis<br />
Depression for more than 2 weeks<br />
Anxiety or OCD<br />
Tics/Tourettes<br />
--------.----.-.--.--<br />
Drug abuse .. ________.___.___..__.____._____.___<br />
.-----.-.-<br />
Antisocial behavior (assaults, thefts, criminal behavior, arrests )____._.._____.__._......_._.__..____.__._____.___._._...____._.._<br />
Family history<br />
Physicalabuse ....__.._______..____._.__.__._._______._...._.____.___._._..._________..__.._<br />
Sexual abuse ---~_M M M M__<br />
Neglect/emotional abuse ____.___.__..__._._.._.___..___._...<br />
comments:<br />
..------------<br />
.-------.------.------------.--..-----..-...---..-..--.---.--.----.--.-.-.----.----..-..--.<br />
.-...-----.--.-------.-..--------.----------.--.--.---.-------..-----.--..---.-----.-----..---.---<br />
~ ~.----<br />
~--~--_._------------<br />
----.-.--..------.- ~ N____.<br />
~_._".._._._...__.__._-<br />
._~-----_._--_.._----_._--<br />
THANK YOU FOR YOUR TIME AND ATTENTION II<br />
'--.