new patient form - Helen DeVos Children's Hospital

35 Michigan Street ne Suite 3003Grand Rapids, mi 49503616.267.2830 fax 616.267.9024devoschildrens.orgPatient NameQuestionnaireinitial - outpatient, pediatric psychologyPage 1 of 6Appointment dateidentifying informationChild’s name Date of birth AgeAddressPhoneStreet City Zip codeGender: Male FemaleRace: African American Asian Caucasian Latino Native American OtherLanguage spoken in the homequestionnaireReason for referral: What questions do you hope to get answered from this appointment?DOBMRNPhysicianFINConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.Grade level your child is currently inNo school Pre-Kindergarten/Young 4/5’s Kindergarten 1 st 2 nd 3 rd 4 th 5 th6 th 7 th 8 th 9 th 10 th 11 th 12 th College Home schooledCurrent schoolSchool districtHas your child experienced any of the following in school?Learning problems Social problems Behavior problems Emotional problemsDoes your child receive any special education assistance?No YesHas your child received any of the following classification or special education services?ASD ConsultantOther Health Impairment (OHI)Autism Spectrum DisorderPhysical therapyCognitively Impaired (CI)Physically Impaired (PI)Early Childhood Developmental Delay (ECDD) Pre-primary Impaired (PPI)Early-onSchool social work servicesEmotionally Impaired (EI)Severe Multiple Impairment (SXI)Head StartSpeech and language impairmentHearing Impaired (HI)Teacher’s aid/paraprofessionalLearning Disabled (LD)Traumatic brain injuryOccupational therapyVisually Impaired (VI)over do not mark below this line barcode zone do not mark below this lineX12795 (10/12) – Page of 6*X12795*

initial - outpatient, pediatric psychology (continued)Page 2 of 6questionnaire (continued)Has your child received any academic or psychological testing done at school or elsewhere?NoYes If yes, where?Academic performanceConsistently above average (A’s, B’s)Previously strong grades, recent dropConsistently average grades (B’s, C’s) Dropped out of school (age: )Consistently below average (C’s, D’s)Graduated from high schoolConsistently below average to failing (C, D, F’s)Was your child ever:Held back - What grades?SuspendedExpelledIs your child experiencing any of the following?Behavior problems:Alcohol/drug useHitting/pushing/physical violenceHurting selfLying/stealingemotional problems:AngerAnxiety/fears/worriesDepression/sadnessFunctional problems:Eating problemsLack of energyMemory problemsPhysical pain/injuryOther presenting problems:Anger outburstsBed wettingClumsyDaydreamingDestructiveDisobedientDistractibleEating problemsFearfulFire settingHead bangingImpulsiveIrritableLacks initiativeMean to othersOveractivePeer conflictRefusal to attend schoolYellingOtherMoodinessOtherPoor hygieneRecognition of dangerSleep problemsSocial relationshipsRockingRunning awaySexual troubleShort attention spanShySlowSoiled pantsStrange behaviorStrange thoughtsStubbornSuicide talkTrouble with the lawTruancyUndependableVery unhappyWithdrawnConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.X12795 (10/12) – Page of 6continued on page 3

Patient NameDOBMRN35 Michigan Street ne Suite 3003Grand Rapids, mi 49503616.267.2830 fax 616.267.9024devoschildrens.orgPhysicianFINConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.initial - outpatient, pediatric psychology (continued)Page 3 of 6questionnaire (continued)Developmental historyWas your child adopted? No YesWas your child born: Full term Premature If premature, born at how many weeks?What were the complication of concerns during pregnancy for the mother?AnemiaPlacenta previaDepressionPre eclampsiaGestational diabetesPrenatal drug/alcohol exposureHeart diseaseSexually transmitted diseaseNoneToxemiaOthermode of delivery: Vaginal Cesarean Emergency cesareanWere there any concerns or complications during/immediately following delivery?Baby’s heart rate droppedMeconium aspirationBorn “blue”Neurological concernsBreechSignificant jaundice (bilirubin)Cord wrapped around neck/nuchal cord Treatment in the Neonatal Intensive Care UnitForceps/suction used(list reason)Low Apgar scoresTemperament as an infant: Easy Withdrawn Difficult OtherBonding: Cuddly Withdrawn Clingy Otherdevelopmental milestones (list age child was competent for each milestone):Crawling No Yes Age Pointed at objects No Yes AgeWalked alone No Yes Age Toilet trained No Yes AgeBabbled No Yes Age Used pencil/crayon No Yes AgeSpoke first word No Yes AgeMedical historyPrimary care physician (pediatrician)has child had any serious illnesses? No Yes If yes, listdoes the child have any disabilities? No Yes If yes, listX12795 (10/12) – Page of 6over

initial - outpatient, pediatric psychology (continued)Page 4 of 6questionnaire (continued)Medical history (continued)has the child been hospitalized? No Yes If yes, listhas the child had any operations? No Yes If yes, listhas the child had any accidents? No Yes If yes, listis the child on any medications? No Yes If yes, listDoes the child have any chronic medical conditions? No Yes If yes, listHas the child ever experienced any of the following?Appetite problemsLoss of consciousnessBronchitis, pneumoniaMeningitis, encephalitisChronic allergiesSeizuresChronic ear/sinus infectionsSleep problemsDiabetes/blood sugar problemsThyroid or endocrine problemsDizzinessTicsHead injuryUnexplained fever or spike temperatureHearing problemsUpper respiratory problems/asthmaHeart problemsVision problemsHigh fever requiring hospitalizationPsychiatric historyhas the child been diagnosed with any of the following?ADHD/ADDEncopresis/enuresisAnxiety disorderExpressive Language DisorderAsperger’s disorderObsessive Compulsive DisorderAutism Spectrum DisorderReactive Attachment DisorderBipolar DisorderReceptive Language DisorderCognitive impairmentTic DisorderDepressive DisorderTourette’s DisorderEating DisorderOtherhas your child received any previous psychiatric treatment or counseling? No YesCurrent or past providersPsychologists/social workers/counselorsConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.PsychiatristsX12795 (10/12) – Page of 6continued on page 5

Patient NameDOBMRN35 Michigan Street ne Suite 3003Grand Rapids, mi 49503616.267.2830 fax 616.267.9024devoschildrens.orgPhysicianFINConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.initial - outpatient, pediatric psychology (continued)Page 5 of 6questionnaire (continued)Family HistoryPrimary CaretakerChild currently lives with:Biological parents (married or cohabitating)Foster or adoptive familyOtherPersons living in the child’s home (including yourself)NAMebiological family psychiatric historyADHD, ADD, impulsivityAutism spectrum disorderAnxiety, panic attacksBipolar-disorder (Manic-depression)Alcohol/drug abuseSchizophrenia or other psychotic/delusionaldisorderBiological parent (divorced/separated)With visitation of other parentWithout visitation of other parentAGe relationship to child quality of relationshipGood Fair PoorGood Fair PoorGood Fair PoorGood Fair PoorGood Fair PoorGood Fair PoorCardiopulmonary difficultiesLearning disorder, learning problemsDepressionSpecific genetic problemSpecific neurological disorderOthersignificant traumaInjured in an accident (explain) Physical abuse NeglectSexual assault/abuse Death/lossEmotional abuseOtherSocial relationshipsWhat word best describes the child?Friendly Withdrawn Few friendsPopular Socially awkward No friendsLeader Shy - Interested in friends Not interested in friendsUsed to have more friendsX12795 (10/12) – Page of 6over

initial - outpatient, pediatric psychology (continued)Page 6 of 6questionnaire (continued)social relationships (continued)describe your child’s interactions with adultsDescribe your child’s interactions with other childrenWho does your child count on when upset?how would you describe your child’s personality and/or temperament?Active Easy QuietDifficult Fussy Slow to warm upEasily upset Happy go lucky Otherany other information you think might be helpful/you would like us to know?DatePerson Completing Questionnaire signatureIf not patient, relationship to patientConfidentiality of this medical record shall be maintained except when use or disclosureis required or permitted by law, regulation, or written authorization by the patient.X12795 (10/12) – Page of 6