Child/Adolescent Personal History Form
(complete if patient is age 17 or under)
Child’s Name: ______Birth Date: ______/______/______
Last First Middle
Phone # : ______Who is the custodial parent (s)?:______
Emergency Contact: ______Relationship to child: ______
Last First
Why has the child come to treatment? (include signs and symptoms with duration and severity):
______
______
______
What goals would your child like to work on in therapy?:______
______
How does the child feel about being at ABH?:______
FAMILY INFORMATION:
Name / Age / Employer/ School / Marital StatusMother / { }M { } D { } S
Father / { }M { } D { } S
Step-Mom / { }M { } D { } S
Step-Father / { }M { } D { } S
Sibling / { }M { } D { } S
Sibling / { }M { } D { } S
Sibling / { }M { } D { } S
Sibling / { }M { } D { } S
EDUCATION:
School District: ______School Name: ______
Has the child ever been afraid/reluctant to go to school? (Please explain): { }Yes / { } No
______
Present grade: ______Repeated a grade: { }Yes / { } No
Has the child ever had any difficulties with: { }Math { }Reading { }Language { }Speech
Has the child ever had any special education services? { }Yes / { } No
Has the child received any complaints from their school regarding behavior or achievement? { } Yes / { }No
If YES, please explain:______
How does your child relate to peers (please be as specific as possible): ______
Name: ______
SOCIAL/LEISURE INFORMATION:
Social time is usually spent:{ }Alone { }Immediate Family { } Peers
Please describe (interests/hobbies, etc):______
Does the child isolate him/herself from other people: { }Yes / { }No
Does the child have a job? { }Yes / { }No Hours: ______Position: ______
Does the family have financial difficulties: (please describe):______
Other family issues:______
PERSONAL ADJUSTMENT:
How does the child relate to:
Mother: ______
Father: ______
A step-parent: ______
Their siblings:______
Authority figures: ______
ADJUSTMENT DIFFICULTIES:
Please check any of the following that are typical of the child’s behavior:
Feels lonely / Does not share / Feelings of guilt / Sets fires / Bedwetting- pastShy with children / Lacks motivation / Defiant / Poorly organized / Soiling
Shy with adults / Sexual acting out / Aggressive with: / Clumsy / Unusual thinking
Prefers to be alone / Preoccupied with sex / Peers / Takes unneeded risk / Unusual behaviors
Worries / Tics or twitches / Siblings / Short attention span / Destructive
Moody / Compulsive Behav. / Adults / Daydreams / Not always truthful
Sad / Ritualistic Behav. / Stealing from home / Jealousness / Violent behavior
Cries easily / Talks impulsively / Stealing from peers / Overactive / Fails to understand
Expects failure / Acts impulsively / Will not admit blame / Bedwetting- present / Consequences
RELIGIOUS/SPRITUAL BELIEFS:
Mother's Background:______Father's Background:______
Does the family practice a religion or spirituality? Please describe:______
______
CULTURAL/ETHNIC BACKGROUND:
{ } African-American { } Caucasian { } Native American { } Hispanic { } Asian-American { } Other: ______
Would you like the therapist to cover any racial/cultural issues? { }Yes / { }No Explain:______
______
Name:______
LEGAL INFORMATION:
Is the child currently facing any pending charges or convictions? { }Yes / { } No
If yes, please explain: ______
Has the child ever been or currently is on probation? { }Yes / { } No
If yes, please explain: ______
Has the child ever been arrested or spent time in a corrections facility? { }Yes / { } No
If yes, please explain:______
Has the child ever been or currently is a part of a divorce or custody issue? { }Yes / { } No
If yes, please explain:______
Is the child adopted?{ } Yes / { } No Have they been told? { }Yes / { }No If so, when? ______
HEALTH HISTORY:
Physician Name: ______Office phone number: ______
Address of Physician: ______
Street address City State Zip
Child's Height:______Child's Weight:______
Has your child NOW or EVER experienced physical abuse/violence?: { }Yes { }No If Yes, please explain:______
______
Was it reported to authorities (explain):______
Has your child NOW or EVER experience sexual abuse/violence?: { } Yes { } No If Yes, please explain:______
______
Was it reported to authorities (explain):______
Has your child NOW or EVERexperienced emotional abuse?: { } Yes { } No If Yes, please explain:______
______
Was it reported to authorities (explain):______
______
Is your child experiencing any physical pain at this time? { } Yes { } No If Yes, please explain (location, severity (see below), date of onset, treatment)______
______
Pain Rating Scale:
(Circle One)______
0 1 2 3 4 5 6 7 8 9 10
No Pain Mild Moderate Severe Very Severe Worst Possible Pain
Are the child’s immunizations up to date? { }Yes / { }No Has the child had an eye exam? { }Yes / { }No
Has the child had a hearing exam? { }Yes / { } No Has she begun menstruation? { }Yes / { }No age: _____
{ }Glasses { } Hearing deficiency
Date of last physical exam: ______Results: ______
What is the present health of the child? please describe:______
______
Name: ______
Past Health Problems: Hospitalizations, Diseases, Accidents, Abortions, or Disability?______
Any emotional disorders in extended family? { } Yes { } No If Yes, please explain:______
______
Any alcohol or drug abuse in the immediate and/or extended family? { } Yes { } No If Yes, please explain: ______
______
Any involvement with alcohol or illicit drugs by the child/adolescent: { } Yes { } No If Yes, please explain:______
______
BIRTH AND DEVELOPMENT:
Pregnancy:Normal?:{ }Yes / { }No Complications? { }Yes / { }No
Please explain: ______
Length of labor: ______Premature? { }Yes / { }No Weeks/Weight: ______
Newborn’s health: ______
Infancy:
Please check all that apply:
{ }Colic / { }Overactive / { }Constipation{ }Eating issues / { }Underactive / { }Chronic illness
{ }Sleeping issues / { }Infections / { }High fevers
{ }Milk or food allergies / { }Fussy / { }Hospitalization
{ }Sleep pattern issues / { }Cried often / { }Surgery
{ } Other______
EARLY CHILDHOOD DEVELOPMENTAL MILESTONES (indicate age started):
Talking: Single words at ____ months; sentences at____ months; walking at____ months;
Began toilet training at____ months; completed toilet training at;____ months; knew colors at____ months;
knew numbers at____ years; knew letters at____ years;
MEDICATION HISTORY:
Is your child allergic to any medication or drugs? { } Yes { } No If Yes, please explain______
______
Family history of medical problems? (explain): ______
______
Please list all medications the child is now taking. Also, please list all supplements, herbal remedies, and over the counter medications.
Name of Medication Dosage Frequency Reason for Using Prescribed by
______
______
Name: ______
NUTRITIONAL SCREENING:
Have your child gained weight or lost weight in the last 30-60 days? { }Yes / { } No If yes, how much and why? ______
Do you have any diet or nutritional concerns? { }Yes / { }No If, yes, please explain: ______
Do you have any food allergies? { }Yes / { }No If yes, please list: ______
Do you have any other concerns about your child's diet or food intake? { }Yes / { } No If yes, please explain:______
______
COUNSELING/PRIOR TREATMENT HISTORY:
Has your child ever spoken about or is CURRENTLY experiencing any of the following:
{ }Suicidal ideas/ expression { }Homicidal ideas/ expression{ }Physical Violence{ }None of the above
Please explain: ______
Has your child had psychotherapy/counseling before? { } Yes { } No If Yes, indicate inpatient or outpatient and name of facility/physician/therapist): ______
______
Length of stay, if hospitalized:______Number of admissions:______
Identify when child was in treatment and for what reason (s):______
______
______
Why did you stop treatment then?______
Any other information you would like to add:______
PLEASE REVIEW THIS FORM AND ENSURE THAT YOU HAVE COMPLETED ALL QUESTIONS OR INDICATE N/A IF NOT APPLICABLE.
I ATTEST THAT I HAVE DISCUSSED ANY QUESTIONS WITH THERAPIST REGARDING THIS FORM.
______
Signature of Informant Date
I have reviewed this questionnaire with the patient/informant:
______
Signature of Clinician/Credentials Date