Psychiatry Patient Information Form Ages 17 and Under

Psychiatry Patient Information Form Ages 17 and Under
(To be completed by patient’s parent/guardian)
Date*
MM slash DD slash YYYY
Name*
First Last
Preferred Name:
Date of Birth*
MM slash DD slash YYYY
Age:*
Parent/Guardian Contact Name(#1):*
Parent/Guardian Contact Phone (#1) :*
Parent/Guardian Contact Name Email (#1)*
Parent/Guardian Contact Name(#2):
Parent/Guardian Contact Phone (#2) :
Parent/Guardian Contact Name Email (#2)
Who referred your child?*
What was their concern?
What is your primary concern(s)?
If applicable, what is the school’s primary concern(s)?
When did you first develop or become aware of these concerns?
FAMILY INFORMATION
Who has legal custody or guardianship of the child:*
Parent/Caregiver/Guardian 1:
Name
First Last
Relationship to child:
Phone
Date of Birth
MM slash DD slash YYYY
Age:
Address (if different from the child’s)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Highest level of education:
Occupation:
Parent/Caregiver/Guardian 2:
Name
First Last
Relationship to child:
Phone
Date of Birth
MM slash DD slash YYYY
Age:
Address (if different from the child’s)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Highest level of education:
Occupation:
Please identify marital status including dates of all marriages/divorces/separations/remarriages for the child’s parents:
Please provide the following information regarding the child’s full siblings, half siblings, step-siblings, or children living in the home: 1. Name 2. Age 3. Grade/Occupation 4. Relationship to Patient 5. Where do they live? (Mom’s, Dad’s, etc.)
List any other adults or family members who are currently living in the home their relationship the child:
List dates of any moves and for what reasons.
How long has the child lived at their present address?
DEVELOPMENTAL INFORMATION
Length of Pregnancy
Birth Weight
Planned or unplanned pregnancy
Any complications during the pregnancy?
Any tobacco, alcohol, or substance use during the pregnancy?
Type of Delivery (C-section, Vaginal):
Any complications during the delivery or right after birth?
If child was adopted, from where?
At what age was child adopted?
Age of parent(s) at time of birth or adoption:
How old was your child when they first began to: Talk
How old was your child when they first began to: Walk
When were they full toilet trained
Any current concerns regarding your child’s physical or social development?
EDUCATION HISTORY
What school is your child currently attending school?
What grade are they in?
Do they have any academic accommodations (such as an IEP or 504 plan, Special Education, etc.)?
If so, when did these first begin?
Any concerns regarding school attendance? Learning?
Has your child every been held back or repeated a grade?
SOCIAL INFORMATION
What does your child like to do for fun?
Are they involved in any extra-curricular activities?
Is your child currently dating or in a relationship?
Is your child currently employed?
Does your child have any legal issues?
Please note any significant losses or events that have impacted your child’s life and when they occurred:
History of Trauma and/or Abuse: (if checked, please explain)
- Life threatening traumatic event of self
- Life threatening event of another
- Domestic Abuse (either witnessed or received)
- Physical Abuse
- Emotional/Verbal Abuse
- Sexual Abuse
- Abandonment/Neglect
- Other
- Not Applicable
Describe: Life threatening traumatic event of self
Describe: Life threatening event of another
Describe: Domestic Abuse (either witnessed or received)
Describe: Physical Abuse
Describe: Emotional/Verbal Abuse
Describe: Sexual Abuse
Describe: Abandonment/Neglect
Describe: Other:
GENERAL MEDICAL INFORMATION AND HISTORY
Primary Care Clinic/Location:
Primary Care Physician’s (PCP) Name:
Other medical providers your child sees (Names, locations, & specialties)
Please list any allergies to medications:
Current Physical Health Conditions:
Previous Medical Hospitalizations (if so, when):
Previous Surgeries (if so, when):
Does your child have any history of significant head injury, concussion, or seizure (if so, when)?
Substance Use History
(Fill only those fields that apply to you)
Alcohol: Current:
- Yes
- No
Alcohol: Age of First Use
Alcohol: Age/Date Last Used
Alcohol: Specific Type Used
Benzodiazepines (Xanax, Klonopin and other ... pams) Current:
- Yes
- No
Benzodiazepines (Xanax, Klonopin and other ... pams) Age of First Use
Benzodiazepines (Xanax, Klonopin and other ... pams) Age/Date Last Used
Benzodiazepines (Xanax, Klonopin and other ... pams) Specific Type Used
Meth, Cocaine, Crack Current:
- Yes
- No
Meth, Cocaine, Crack: Age of First Use
Meth, Cocaine, Crack Age/Date Last Used
Meth, Cocaine, Crack Specific Type Used
Hallucinogens Current:
- Yes
- No
Hallucinogens Age of First Use
Hallucinogens Age/Date Last Used
Hallucinogens Specific Type Used
Narcotic Pain Pills or Heroin Current:
- Yes
- No
Narcotic Pain Pills or Heroin Age of First Use
Narcotic Pain Pills or Heroin Age/Date Last Used
Narcotic Pain Pills or Heroin: Specific Type Used
Inhalants: Current:
- Yes
- No
Inhalants: Age of First Use
Inhalants:Age/Date Last Used
Inhalants: Specific Type Used
Cannabis/Marijuana: Current:
- Yes
- No
Cannabis/Marijuana: Age of First Use
Cannabis/Marijuana: Age/Date Last Used
Cannabis/Marijuana: Specific Type Used
Nicotine/E-Cigs: Current:
- Yes
- No
Nicotine/E-Cigs: Age of First Use
Nicotine/E-Cigs: Age/Date Last Used
Nicotine/E-Cigs: Specific Type Used
OTC Diet: Current:
- Yes
- No
OTC Diet: Age of First Use
OTC Diet: Age/Date Last Used
OTC Diet: Specific Type Used
Other/Synthetic: Current:
- Yes
- No
Other/Synthetic: Age of First Use
Other/Synthetic: Age/Date Last Used
Other/Synthetic: Specific Type Used
Natural Supplements: Current:
- Yes
- No
Natural Supplements: Age of First Use
Natural Supplements: Age/Date Last Used
Natural Supplements: Specific Type Used
Caffeine: Current:
- Yes
- No
Caffeine: Age of First Use
Caffeine: Age/Date Last Used
Caffeine: Specific Type Used
Please describe any previous chemical dependency treatment:
PSYCHIATRIC HISTORY
Past and Current Mental Health Diagnoses:
Past and Current Mental Health Services (include date(s) and program name):
Past Psychiatric Providers/Physicians:
Past Hospitalizations for Mental Health (include date, location, reason):
Past Psychiatric Medications (Please include medication name, dose, side effects, effectiveness, and dates taken):
Current Medications (Prescribed psychiatric & non-psychiatric, over the counter, and supplements):
Who prescribes your current psychiatric medications:
FAMILY MEDICAL AND PSYCHIATRIC HISTORY
Please check which, if any, of the following conditions/problems apply to your child’s blood relatives. If other significant mental health problems are present among blood relatives, please list those in the space provided below.
Anxiety Disorders
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Panic Disorder
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
OCD
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
PTSD/Trauma
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Major Depression
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Bipolar Disorder
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Psychosis/Schizophrenia
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Substance-Related or Addictive Disorders
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Eating/Feeding Disorders
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Personality Disorders
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Sleep Disorders
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Suicide Attempts
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Self-Injurious Behaviors
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Autism Spectrum Disorder
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Tics/Tourette Disorder
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
ADHD/ADD
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Learning Disorder
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Intellectual Disability
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Enuresis/Encopresis
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Dissociative Disorder
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Legal Problems
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Other significant mental health problems that apply to your child’s blood relatives
FAMILY MEDICAL AND PSYCHIATRIC HISTORY
Please check which, if any, of the following conditions/problems apply to your child’s blood relatives. If other significant physical health problems are present among blood relatives, please list those in the space provided below.
Heart Attack
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Arrythmias
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Coronary Artery Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Heart Failure
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Stroke
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Seizure(s)
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Peripheral Artery Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
COPD
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Cancer/Malignancy—type
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Endocrine Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Diabetes
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Thyroid Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
GI disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Liver Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Pancreatitis
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Renal/Kidney Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Skin Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Blood Clotting Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Urologic Disease
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Genetic / Congenital Condition
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Sudden death prior to age 50
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
HIV/AIDS
- Mother
- Father
- Brother(s) list name
- Sister(s) list name
- Other
If Brother(s) and/or Sister(s) selected, please list name(s):
If Other selected, please describe):
Other significant physical health problems that apply to your child’s blood relatives:
REVIEW OF SYSTEMS
(99204 complete 2-9 including system related to presenting problem) (99205 need to complete 10)
Constitutional
Weight Loss
- Yes
- No
Fatigue
- Yes
- No
Fever
- Yes
- No
Eyes
Glasses/Contacts
- Yes
- No
Eye Pain
- Yes
- No
Double Vision
- Yes
- No
Decreased Vision
- Yes
- No
Ears, Nose Throat
Difficulty Hearing
- Yes
- No
Ringing in Ears
- Yes
- No
Vertigo
- Yes
- No
Difficulty Swallowing
- Yes
- No
Pain
- Yes
- No
Cardiovascular
Murmur
- Yes
- No
Chest Pain
- Yes
- No
Palpations
- Yes
- No
Dizziness
- Yes
- No
Fainting Spells
- Yes
- No
Shortness of Breath
- Yes
- No
Difficulty Lying Flat
- Yes
- No
Swelling Ankles
- Yes
- No
Respiratory
Cough
- Yes
- No
Illness
- Yes
- No
Pain
- Yes
- No
Shortness of Breath
- Yes
- No
Use of Inhaler
- Yes
- No
Use of Oxygen
- Yes
- No
Gastrointestinal
Heartburn/Reflux
- Yes
- No
Nausea/Vomiting
- Yes
- No
Constipation
- Yes
- No
Change in BMs
- Yes
- No
Jaundice
- Yes
- No
Abdominal Pain
- Yes
- No
Black or Bloody BM
- Yes
- No
Genitourinary
Burning/Frequency
- Yes
- No
Nighttime Frequency
- Yes
- No
Blood in Urine
- Yes
- No
Erectile Dysfunction
- Yes
- No
Abnormal Discharge
- Yes
- No
Bladder Leakage
- Yes
- No
Musculoskeletal
Joint Pain/Swelling
- Yes
- No
Stiffness
- Yes
- No
Muscle Pain
- Yes
- No
Back Pain
- Yes
- No
Skin
- Yes
- No
Hair Loss
- Yes
- No
Rash/Hives
- Yes
- No
Lesions/Sores
- Yes
- No
Itching/Burning
- Yes
- No
Easy Bruising
- Yes
- No
Neurological
Loss of Strength
- Yes
- No
Numbness
- Yes
- No
Headache
- Yes
- No
Tremors
- Yes
- No
Memory Loss
- Yes
- No
At this time, is there anything else you think I should know about your child?
Name of the person completing this form:*
Relationship to patient:*
Email
This field is for validation purposes and should be left unchanged.

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p: 952.544.6806

Psychiatry Patient Information Form Ages 17 and Under

Psychiatry Patient Information Form Ages 17 and Under

FAMILY INFORMATION

DEVELOPMENTAL INFORMATION

EDUCATION HISTORY

SOCIAL INFORMATION

GENERAL MEDICAL INFORMATION AND HISTORY

Substance Use History

PSYCHIATRIC HISTORY

FAMILY MEDICAL AND PSYCHIATRIC HISTORY

FAMILY MEDICAL AND PSYCHIATRIC HISTORY

REVIEW OF SYSTEMS

Choices Psychotherapy

Office: 952-544-6806

Locations

Minnesota Areas Served

Hours

Telemental Health Program Certified

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