Child History Form

Being prepared for your child's Appointment

Please complete and submit this background form prior to your child's appointment. If you have any questions or need help, please give us a call. If you have been feeling sick within the past 24 hours, please reschedule your appointment.

Phone number 859-200-1990

Child Information

Appointment date

Child's Social Security Number

First name

Last name

Child's age

Date of birth

Child's current address

Distance traveled to office:

Name of person bring child to office

Person bringing child MUST have legal guardianship or a written statement signed by legal guardian authorizing transportation and evaluation of child.

Parent Information

Mother's first name

Last name

Current address

Father's first name

Last name:

Current address

Social History

Type of home child lives in:

House

Apartment

Trailer

owned

rented

Number of people in the home who are employed:

Number of people in the home receiving SSI /SSDI:

If yes, when, and briefly what was the reason for Social Services involvement:

Report any family history of mental health problems, drug problems and/or legal problems:

Developmental History

State where the child was born:

Number of days child stayed in the hospital after birth:

Child was delivered:

Naturally

Scheduled C-Section

Emergency C-Section

Btwn 38-42 wks gestation

37 wks gestation or earlier

43 wks gestation or later

List any problems with pregnancy or delivery:

Child's birth weight:

Report any birth defects or injuries as an infant:

Report age when child started crawling:

started walking:

completely toilet trained:

Report age when child started babbling:

started using words:

started using sentences:

Educational History

Current Grade:

School name:

What grades does child earn:

Has the child repeated any grades? If so, which grade?

List child's participation in school activities:

Clubs, after-school activities, sports, band, etc.

List problem child has in school. When did problem begin? Who has tried to correct the problem, and how did they try to correct it:

Physical History

Date of last physical exam:

Name of physician:

List any injuries, accidents, and any need for hospitalization:

Is the child accident prone? If yes, why do you think so?

Please list the medications for physical conditions the child is taking. Include the dosage and amount.

Psychiatric History

Date of last appointment for behavioral or mental health symptoms:

Name of doctor prescribing medicine for behavior or mental health symptoms:

When did the behavior, mental health or psychiatric problem begin and when did treatment begin?

List names of hospital(s) and dates for inpatient treatment for behavior or mental health problems:

List names of residential facility, dates, and reason for placement:

Please list the medications the child is taking for behavioral or mental health problems. Provide dosage and amount.

Name of counselor and facility, start of service, and reason for counseling:

List any changes as a result of using medication and/or participating in counseling or other services:

Daily Activities

Time the child goes to bed and gets up on school days:

Time child goes to bed and gets up on non-school days:

Describe child's sleep:

Describe child's appetite:

Describe child's ability to bathe, dress, and brush his hair and teeth:

List child's chores and responsibilities:

Report what the child likes to play, who the child likes to play with, and ability to get along with playmates:

Describe child's behavior in the home with others, cooperation with chores and routines:

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Child History Form

Being prepared for your child's Appointment

Child Information

Parent Information

Social History

Developmental History

Educational History

Physical History

Psychiatric History

Daily Activities

Being prepared for your child's Appointment

Annette Freel, M.S., L.P.P.

Licensed Psychological Practitioner