Psychiatry Patient Information Form Ages 17 and Under

(To be completed by patient’s parent/guardian)

Date*

Name*

First Last

Preferred Name:

Date of Birth*

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

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

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:*

Comments

This field is for validation purposes and should be left unchanged.

p: 952.544.6806

Psychiatry Patient Information Form Ages 17 and Under