PSYCHIATRIC EVALUATION HISTORY

Client name*

First Last

Date of birth*

Pediatrician/Primary care provider

Date of last physical

Is the child currently on any psychotropic medications?*

Yes
No
Don’t know

If yes, please list known psychotropic medications

Is the child currently taking any prescription or Over-the-Counter medication (including supplements e.g. vitamins, herbs, CBD, etc.)*

Yes
No
Don’t know

If yes, list known prescriptions or over-the-counter medications:

Medical History

Has the child ever :

Had a concussion*

Yes
No
Don’t know

Been hospitalized overnight*

Yes
No
Don’t know

Been diagnosed with a chronic medical condition*

Yes
No
Don’t know

Been in a serious accident*

Yes
No
Don’t know

Had surgery*

Yes
No
Don’t know

Family medical history

Does anyone in the family have (or had) any of the following conditions?

Developmental delays*

Yes
No
Don’t know

Learning problems, such as dyslexia or poor reading*

Yes
No
Don’t know

Autism or Asperger’s Syndrome*

Yes
No
Don’t know

Attention Deficit (ADD/ADHD)*

Yes
No
Don’t know

Tics or Tourette syndrome*

Yes
No
Don’t know

Depression or anxiety*

Yes
No
Don’t know

Suicidal thoughts or behaviors*

Yes
No
Don’t know

Schizophrenia or bipolar disorder*

Yes
No
Don’t know

Gambling issues*

Yes
No
Don’t know

Alcohol overuse*

Yes
No
Don’t know

Other substance use concerns*

Yes
No
Don’t know

Cardiac disease, including sudden death*

Yes
No
Don’t know

Diabetes*

Yes
No
Don’t know

Migraine or other chronic headache*

Yes
No
Don’t know

Thyroid disease*

Yes
No
Don’t know

Weight management issues*

Yes
No
Don’t know

Cancer*

Yes
No
Don’t know

Other major medical illness*

Yes
No
Don’t know

Developmental History

Did mother have prenatal care?*

Yes
No
Don’t know

Medical or psychiatric problems during pregnancy?*

Yes
No
Don’t know

Medications during pregnancy?*

Yes
No
Don’t know

Nicotine during pregnancy?*

Yes
No
Don’t know

Other substance use during pregnancy?*

Yes
No
Don’t know

Problems with eating/sleeping in infancy?*

Yes
No
Don’t know

Any allergies or reflux in infancy?*

Yes
No
Don’t know

Delays in crawling/walking?*

Yes
No
Don’t know

Delays in toileting?*

Yes
No
Don’t know

Delays in speech?*

Yes
No
Don’t know

Problems learning letters/reading?*

Yes
No
Don’t know

Problems learning numbers/math?*

Yes
No
Don’t know

Did child attend preschool?*

Yes
No
Don’t know

Any social problems in preschool?*

Yes
No
Don’t know

Developmental Details

Weeks gestation at birth

Length of labor

Was delivery vaginal or c-section?

Problems during labor/delivery?

Infant weight at birth

Problems at birth? (Ex: given oxygen, put in incubator)

Has the child had any of the following services?

Birth to Three*

Past
Current
Never
Don’t know

School accommodations (IEP or 504 plan)*

Past
Current
Never
Don’t know

Psychological testing (in school)*

Past
Current
Never
Don’t know

Psychological or neuropsychological testing (outside of school)*

Past
Current
Never
Don’t know

Occupational Therapy*

Past
Current
Never
Don’t know

Speech-Language Therapy*

Past
Current
Never
Don’t know

Applied Behavioral Analysis (ABA)*

Past
Current
Never
Don’t know

Psychiatry*

Past
Current
Never
Don’t know

Individual therapy*

Past
Current
Never
Don’t know

Group therapy*

Past
Current
Never
Don’t know

Family therapy*

Past
Current
Never
Don’t know

Intensive Outpatient or Partial Hospital Program*

Past
Current
Never
Don’t know

In-home programs (MDFT, FFT, IICAPS)*

Past
Current
Never
Don’t know

Substance use treatment*

Past
Current
Never
Don’t know

Psychiatric hospitalization*

Past
Current
Never
Don’t know

Court-mandated mental health treatment*

Past
Current
Never
Don’t know

Other

Review of Systems

Other than information provided above, does the child have any other conditions?

General health, such as energy level, difficulty gaining weight, or overweight*

Past
Current
Never
Don’t know

Sleep issues (including snoring)*

Past
Current
Never
Don’t know

Eyes or vision*

Past
Current
Never
Don’t know

Ears or hearing*

Past
Current
Never
Don’t know

Ears or hearing*

Past
Current
Never
Don’t know

Mouth or teeth/dental*

Past
Current
Never
Don’t know

Breathing or respiration, including asthma*

Past
Current
Never
Don’t know

Heart or cardiovascular/circulation*

Past
Current
Never
Don’t know

Digestion or gastrointestinal, including food sensitivities*

Past
Current
Never
Don’t know

Elimination/urination/peering or genitourinary*

Past
Current
Never
Don’t know

Muscles/bones or musculoskeletal*

Past
Current
Never
Don’t know

Nerves/brain or neurological, such as starting spells, shaking, or seizures*

Past
Current
Never
Don’t know

Skin, including eczema, birthmarks, or rashes*

Past
Current
Never
Don’t know

Endocrine or hormones*

Past
Current
Never
Don’t know

Blood or hematologic*

Past
Current
Never
Don’t know

Behavior, including lying, stealing, setting fires, or cruelty to animals*

Past
Current
Never
Don’t know

For female children:

Has the child started menstruation?

Yes
No

If menstruation started, at what age?

Are periods regular?

Yes
No

Any mood concerns associated with cycle?

Yes
No

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forms – Psychiatric Development

Psychiatric Development – English (rev 20200504)