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

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