Parent Application Form

C2 Your Health, PC

PARENT APPLICATION FORM

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Instructions to parents: Please complete this form, writing N/A if items do not apply.

Person completing form:______Date form completed:______

Child's name:______Sex: M F Birthdate: ______

Home Phone:______Caretaker's Mobile Phone:______

School:______Grade:______Religion:______

If the child does not live with the mother or father, please note this below the parent names

Mother's Name:______Age:______Education:______

Occupation:______Place of residence: ______

Father's Name:______Age:_____ Education:______

Occupation:______Place of residence: ______

This child is in legal custody of:______

Stepparent(s) -- give names, ages, education, occupation, and date of marriage to natural parent.

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Other Children in Family:

First and Last Name AgeFirst and Last Name Age

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Others living in the home:______

Place a star (*) in front of the names of the people who live in the child's home.

Please provide a brief history of the family: ______
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CHIEF PROBLEM: (Tell us about your child's difficulties, when and how they began, and what you hope we can do to help.)

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Other Problems: (Legal or police problems, peculiar behavior, eating difficulties, etc.)

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How have the above problems affected your family?

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Family Problems: (Tell us about marital or financial problems, psychiatric illnesses or emotional problems, alcoholism, drug abuse or major upsetting events in the family.)

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Mother's Pregnancy: Under doctor's care: Yes_____ No_____

If you experienced any of the problems listed below, please indicate the month of pregnancy in which they occurred.

Bleeding______Injury______Describe______

Threatened miscarriage ______Early contractions______High blood pressure______

Toxemia______Anemia______Flu ______

Vomiting______Swollen ankles______Measles______

Other serious illenesses______

List any medications mother took during pregnancy:______

How was mother’s emotional state during pregnancy?______

While pregnant, did mother smoke?______, drink alcohol?______, use drugs?______

Birth History:

Type of delivery: Vaginal______Cesarean______

Premature?______If yes, how many weeks early?______

Total hours spent in labor:______Induced or spontaneous labor?______Twins?______

Other Complications:______

Length of hospital stay______

Newborn's condition: Good_____ Fair_____ Poor_____ Apgar rating if known______

Color: Normal_____ Blue_____ Yellow_____ Birth Weight_____ If adopted, at what age?______

If infant required oxygen, for how long was it used?______

MEDICAL HISTORY OF CHILD: (Indicate the age at which your child had any of the following medical problems or illnesses.)

Measles______Flu______Seizures______

Mumps______Meningitis______Allergy______

Encephalitis______Injuries to head______High Fever______

Other serious injuries or illnesses______

Hospitalizations or operations: ______

Does you child have staring, fainting, or falling spells?______Describe:______

Has your child had regular immunizations?______

Current medication(s)?______

Medication Allergies?______

DEVELOPMENTAL HISTORY: (as best as you can remember)

Give the age at which your child was able to do each of the following things:

First smile______Said "No! No!" to most things______

Rolled over______Held up arms to be picked up______

Sat alone______Held cup to drink______

Crawled______Fed self______

Walked with help______Used fork______

Walked alone______Helped dress self______

Used 4-10 words______Dressed self except for difficult buttons/zippers______

Used sentences______Stopped wetting at night______

Talked clearly______Toilet trained______

PERSONALITY OF CHILD:

Description of personality:______

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Who is the child very close to?______

What kind(s) of discipline work best with this child?______

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How does this child get along with other children?______

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What does you child do for fun?______

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EDUCATIONAL HISTORY:Child's grade:______School:______

What areas are your child best in?______

What areas are difficult for your child?______

Has your child ever repeated a year of school?______If so, which year(s)?______

Does your child receive any special classes or services at school?______If so, describe:______

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CHILD'S DOCTOR: Please give us your child's primary doctor's name and address in the space below

Name:______

Address:______

City:______State:______Zip:______

Phone:______

PREVIOUS EVALUATION OR TREATMENT:

If your child has been seen for evaluation or treatment (including individual, psychological testing at school) by a mental health professional (psychiatrist, psychologist, social worker, etc.) please list who, where and when in the space below.

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