Child & Adolescent Behavioral Health Information

This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability unless you are requested to skip over a question.

1. Name of the Client

2. Name of person completing this questionnaire and relationship to client.

3. Briefly describe the specific problem(s). Please estimate the length of time the problem has been present.

4. Pediatric Symptom Checklist (c 1988, MS Jellinek & JM Murphy, Massachusetts General Hospital) Emotional and physical health go together in children. Because parents are often the first to notice a problem with their child's behavior, emotions or learning, you may help your child get the best care possible by answering these questions. Please Mark under the heading that best fits your child.

For the following questions, please indicate a

0 Never
1 Sometimes
2 Often

Complains of aches and pains.

0 1 2

Spends more time alone.

0 1 2

Tires easily, has little energy.

0 1 2

Fidgety, unable to sit still.

0 1 2

Has trouble with a teacher.

0 1 2

Less interested in school.

0 1 2

Acts as if driven by a motor

0 1 2

Daydreams too much.

0 1 2

Distracted easily.

0 1 2

Is afraid of new situations.

0 1 2

Feels sad, unhappy.

0 1 2

Is irritable, angry.

0 1 2

Feels hopeless.

0 1 2

Has trouble concentrating.

0 1 2

Less interest in friends.

0 1 2

Fights with others.

0 1 2

Absent from school.

0 1 2

School grades dropping.

0 1 2

Is down on him or herself.

0 1 2

Visits doctor with doctor finding nothing wrong.

0 1 2

Has trouble sleeping.

0 1 2

Worries a lot.

0 1 2

Wants to be with you (parent) more than before

0 1 2

Feels he or she is bad.

0 1 2

Takes unnecessary risks.

0 1 2

Gets hurt frequently.

0 1 2

Seems to be having less fun.

0 1 2

Acts younger than children his or her age .

0 1 2

Does not listen to rules.

0 1 2

Does not show feelings.

0 1 2

Does not understand people's feelings.

0 1 2

Teases others.

0 1 2

Blames others for his or her troubles

0 1 2

Takes things that do not belong to him or her.

0 1 2

Refuses to share.

0 1 2

5. Over the last 4 weeks, how often has your child been bothered by any of the following problems? For the following issues, please use the following scale.

0 Not at all
1 Several Days
2 More than Half the Days
3 Nearly Every Day

Had poor appetite or overeating.

0 1 2 3

Gone on eating binges where he/she has not been able to stop eating.

0 1 2 3

Made him/herself sick (vomited) to control weight.

0 1 2 3

Used laxative, diet pills, or diuretics to control weight.

0 1 2 3

Exercised more than 60 minutes a day to lose or to control weight.

0 1 2 3

6. If you checked off any problems on this questionnaire, how difficult have these problems made it for your child to do his/her work or get along with other people?

Not at all Somewhat Difficult Very Difficult Extremely Difficult

MEDICAL & PHYSICAL HISTORY

7. Who is your child's Pediatrician or Primary Care Physician (PCP)?

8. Pediatrician/PCP Address and Phone Number.

9. Date of last physical exam.

10. It may be beneficial for the therapist to communicate with your child's Pediatrician/PCP. Please check here if you give your consent for us to communicate with your child's Pediatrician/PCP.

Yes No

11. Please list all of your child's medical hospitalizations, including the dates, reasons for the hospitalizations, hospitals and physicians.

13. If your child is being treated for any of the above or any serious medical condition, please describe the treatment.

14. List all prescribed and over the counter medications your child takes regularly.

15. List any drug, medication or other substance to which your child is allergic.

16. Does your child exercise regularly or play a sport?

Yes No

17. Does your child eat a well-balanced diet?

Yes No

PREVIOUS BEHAVIORAL HEALTH TREATMENT

18. Please list all of the behavioral health and chemical dependency treatment your child has had, including dates, therapists or hospital, problem(s) and/or medication(s).

19. Please list family members who have been treated for emotional problems (e.g. anxiety, depression, schizophrenia, suicide), drug/alcohol issues or brain disease (e.g. Alzheimer’s, stroke).

OTHER

20. Are you currently involved in court proceedings or litigations such as child custody, worker’s compensation, auto accident or criminal proceedings? Please explain.

FAMILY HISTORY

21. Please add any additional information that you believe may be helpful.

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