DR HART INTAKE FORM - Pediatric Associates of Abilene

DR. HART INTAKE FORM

This questionnaire will give you the opportunity to describe your concerns about your child. Your answers will be kept strictly confidential. If you are not comfortable answering a question in writing, please indicate and discuss these questions with your physician at the time of your visit.

GENERAL INFORMATION

Patient Name

Date

Person Completing this Form

Relationship to Patient

What do you see as your child's main problem(s) at home?

What do you see as your child's main problem(s) at school?

What are your child's strengths? What is your child especially good at?

How does your child get along with the other children and siblings?

How have your child's problems affected your family?

Why do you think your child acts like they do?

What types of things have you tried in order to help your child with his or her problems?

How do you usually discipline your child?

How consistent are you and your spouse with discipline?

What would you like to see change?

What are you wanting or expecting from this evaluation?

What previous treatments has your child received? What were the results?

Anything else you think we should know or you would like to tell us?

PATIENT HISTORY

Please fill out this form to the best of your abilities. Your answer will give us a. better understanding of your child's problems. Your provider will go over your responses with you during your visit.

MEDICAL HISTORY

Pregnancy and Birth History:

What was your child's birth weight?

Did you deliver vaginally or c-section?

Vaginally C-Section

How many weeks long was your pregnancy?

Did you have any problems during labor or delivery? If yes, what?

Did your child have problems during or after birth? If yes, what?

PRESENT MEDICAL HISTORY

When was your childs last hearing and vision screening?

Is your child on any medications? If yes, please list below. Please include any over the counter medications or supplements.

Does your child have any allergies?

Has your child ever been hospitalized or had surgery? If yes, please list the age and reason.

Are either parents involved in? (Check all that apply)

Does your child eat dirt, paint chips, lint, etc.?

FAMILY HISTORY

Mother's age, years of schooling, & occupation:

Mother's health problems:

Had any miscarriages or stillborn babies?

Father's age, years of schooling, & occupations:

Father's health problems:

Are this child's biological parents divorced? If yes, when?

Please list names of full siblings (same mother and father) and ages:

Please list names of all half siblings and ages:

Who lives in your household now?

Any members of the family not in the house?

Has anyone in either of the biological parent families ever had any of the following?

If so, please elaborate:

SCHOOL HISTORY

What school does your child attend?

School phone number:

Name of teacher:

Current grade level:

What kind of grades is your child getting?

If possible, please attach most recent report card:

When were you first aware of problems with school?

Has your child ever needed any of the following? (Check all that apply)

Has your child ever had educational or psychological tests done? If so, when and by whom?

If possible, please attach a copy of. the testing to this questionnaire:

Any concern of learning disability?

Yes No

Any problems with performance on standardized tests?

Yes No

Is there an IEP or 504 plan in place at school?

Yes No

Any detentions, suspensions, or expulsions?

Yes No

Has patient received any prior counseling?

Yes No

DEVELOPMENTAL HISTORY

At what age did your child:

Sit by themselves:

Say first word:

Crawl:

Say three words:

Walk:

Use 2 word phrases:

Become right/left handed:

Use 3-4 word sentences:

What was your child like as a:

Baby?

Toddler (18 mo - 3 yrs)?

Anything that you think may be significant for us to know?

By checking this box you agree that the information provided in this form is truthful and correct.