Child and Adolescent-General Intake

AMS Psychiatry

Please correct the errors described below.

PARENT OR GUARDIAN: PLEASE COMPLETE AND BRING THIS FORM TO CLINIC

DEMOGRAPHICS:

Who lives in the same household as the child?

Add New Individual

Please select all of the following symptoms that apply to your child:

E

PAST PSYCHIATRIC HISTORY:

If yes, provide the needed information below:

Add New Provider

If yes, provide the needed information below:

Add New Provider

FAMILY HISTORY:

Please select any known psychiatric illnesses in blood relatives of the child:

SUBSTANCE USE HISTORY:

MEDICAL HISTORY:

Biological females only:

MEDICATIONS:

Please list all medication your child is currently taking:

Add New Medication

ALLERGIES:

SOCIAL HISTORY:

DEVELOPMENTAL HISTORY:

(Not all parents remember the answers to these questions. You can write down what you do remember or look back if you kept a baby book.)

How old was the child when he/she was able to:

TESTING HISTORY:

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