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Child and Adolescent Clinical Assessment
Step
1
of
18
5%
Current Date
(Required)
Name of Child
(Required)
Date of Birth
(Required)
Gender
(Required)
Male
Female
Current Weight
(in pounds)
Allergies
(Required)
Drug Intolerances
(Required)
(eg severe diarrhea, headaches, etc)
Current/Active Diagnosis (Problem List)
Pregnancy and Infancy History
Pregnancy History
Mother's age at birth
Father's age at birth
Total # Pregnancies
# Pregnancy for this child
# Premature Births
Please list any supplements/vitamins taken by mother during pregnancy.
# Miscarriages
Infertility Treatments if any
IVF Treatments if any
Was mother on birth control while pregnant?
Yes
No
Which kind?
If yes, what week gestation was it discontinued?
Please list any medicines taken by mother during pregnancy
Please indicate if mother experienced any medical illnesses during the pregnancy
Bacterial illnesses (UTI, GBS+, etc)
Bleeding/spotting
Eclampsia/ HELLP syndrome
Emotional distress/ extreme stress
Gestational diabetes
Hypertension (High Blood pressure)
Pre-eclampsia
Preterm labor
Recurrent yeast infections
Viral illnesses
Vomiting requiring medicines or hospitalization
Other
Other medical illness
How many alcoholic beverages per week consumed while pregnant?
Any dental work done while pregnant?
Yes
No
How many amalgams did mother have while pregnant?
Any occupational exposure to mercury or other toxins while pregnant?
Yes
No
Did mother receive a Rhogam injection during pregnancy?
Yes
No
Did mother receive Tdap or Flu shot during pregnancy?
Yes
No
Was there regular prenatal care while pregnant?
Yes
No
How many ultrasounds done?
Did mother have amniocentesis?
Yes
No
Was house occupied during pregnancy built before 1978 or have any renovation done during pregnancy?
Yes
No
Any special diets during pregnancy? (Vegan, organic, paleo, etc)
Yes
No
Types of fluids consumed during pregnancy (Well/tap water, caffeinated drinks, etc)
How frequently and what type of seafood consumed during pregnancy?
Foreign travel during pregnancy?
Yes
No
If yes, where?
Birth History
Duration of pregnancy with this child
Method of Delivery
Vaginal
Cesarean Section
VBAC
If Cesarean, was it emergency or planned?
Was labor induced?
Yes
No
Epidural?
Yes
No
Birth Weight
Birth Length
Birth Head Circumference
Apgar Scores (if known): 1 min
Apgar Scores (if known): 5 min
Please choose all of the following complications that apply to the delivery of the child:
Drop in fetal heart rate
Fetal distress
Meconium
Forceps required
Vacuum extraction
Cord around neck
Jaundice requiring phototherapy
Transient breathing difficulties
Temporary oxygen or breathing assistance but no NICU needed
Infections/ Fever
Other
Admitted to NICU
Other Complication(s)
If admitted to NICU
Antibiotics
Intubation/ Breathing tube
Pneumonia
Chronic Lung Disease
Feeding tube
Feeding difficulties
Necrotising enterocolitis (NEC)
Intraventricular Hemorrhage (IVH)
Seizures
Periventricular Leukomalacia (PVL)
Congenital Heart Disease/ Patent Ductus Arteriosus
Other
Other NICU Issues
Infancy Dietary History
Infancy Dietary History
Choose all that apply
Breast Fed
Expressed Breast Milk
Formula
Reflux?
Milk/ Formula Intolerances?
Colicky baby?
Infantile eczema?
Special diet/ restrictions required in first year of life?
How long breast fed?
How long expressed breast milk?
Forumula type and reason
Age when started formula
Require reflux medicines?
Yes
No
Which reflux medicine prescribed
Please explain any special diet/ restrictions
Past Developmental History
Age when you first suspected a delay or problem in development
Which of the problem best describes your child
Period of normal development followed by a loss in skills
Period of normal development followed by a plateau, stagnation or non progression of skills
Developmental delay from birth or early in life
Other
Other developmental problem
Age at Communication Milestones (List in months)
First Speech-Like sounds
First Time said “mama” / “dada”
First word besides “mama” and “dada”
First time child used words to refer to something specifically
First time child put words together in a phrase
Pointing
Age at Motor Milestones (List in months)
Rolling Over
Sitting Without Support
Crawling
Creeping/Crawling
Standing Independently
Walking Independently
Potty Trained: Urine
Potty Trained: Stool
If your child lost skills (regressed) please fill out the fields below
Speech
Age when regression occured
Duration of regression
Was regression abrupt or slow
Age at which skill was regained
Fine Motor Skills
Age when regression occured
Duration of regression
Was regression abrupt or slow
Age at which skill was regained
Coordination
Age when regression occured
Duration of regression
Was regression abrupt or slow
Age at which skill was regained
Social Interaction
Age when regression occured
Duration of regression
Was regression abrupt or slow
Age at which skill was regained
Pointing
Age when regression occured
Duration of regression
Was regression abrupt or slow
Age at which skill was regained
Eye Contact
Age when regression occured
Duration of regression
Was regression abrupt or slow
Age at which skill was regained
Multiple episodes of regression
Age when regression occured
Duration of regression
Was regression abrupt or slow
Age at which skill was regained
Was regression associated with any of the following factors?
Viral Illness
Duration
Treatment
Other Details
Seizure
Duration
Treatment
Other Details
Fever
Duration
Treatment
Other Details
Rash
Duration
Treatment
Other Details
Vaccine
Duration
Treatment
Other Details
Mitochondrial dysfunction
Duration
Treatment
Other Details
Past Medical History for Child
Allergic Disorders & Treatments
Please check all that apply and fill in as needed
Asthma
Allergies
Nasal Allergies
Eczema
Food Allergies
Asthma
When Diagnosed
Duration
Treatment
Allergies
When Diagnosed
Duration
Treatment
Nasal Allergies
When Diagnosed
Duration
Treatment
Eczema
When Diagnosed
Duration
Treatment
Food Allergies
When Diagnosed
Duration
Treatment
Neurological Disorders
Please check all that apply and fill in as needed
Microcephaly
Macrocephaly
Hypotonia (low muscle tone)
Hypertonia (increased tone)
Tremor
Ataxia (Unsteadiness)
Apraxia (Poor coordination)
Easy Fatiguability
Exercise Intolerance
Muscle disorder/myopathy
Chronic Headaches
Epilepsy
Febrile Seizures
Nystagmus
Migraines
Head injury/Traumatic Brain Injury
Cerebral Palsy
Tic Disorder
PANDAS/PANS
PITANDS
Tourettes
Landau-Kleffner Syndrome
Other
Microcephaly
When Diagnosed
Duration
Treatment
Macrocephaly
When Diagnosed
Duration
Treatment
Hypotonia (low muscle tone)
When Diagnosed
Duration
Treatment
Hypertonia (increased tone)
When Diagnosed
Duration
Treatment
Tremor
When Diagnosed
Duration
Treatment
Ataxia (Unsteadiness)
When Diagnosed
Duration
Treatment
Apraxia (Poor coordination)
When Diagnosed
Duration
Treatment
Easy Fatiguability
When Diagnosed
Duration
Treatment
Exercise Intolerance
When Diagnosed
Duration
Treatment
Muscle disorder/myopathy
When Diagnosed
Duration
Treatment
Chronic Headaches
When Diagnosed
Duration
Treatment
Epilepsy
When Diagnosed
Duration
Treatment
Febrile Seizures
When Diagnosed
Duration
Treatment
Nystagmus
When Diagnosed
Duration
Treatment
Migraines
When Diagnosed
Duration
Treatment
Head injury/Traumatic Brain Injury
When Diagnosed
Duration
Treatment
Cerebral Palsy
When Diagnosed
Duration
Treatment
Tic Disorder
When Diagnosed
Duration
Treatment
PANDAS/PANS
When Diagnosed
Duration
Treatment
PITANDS
When Diagnosed
Duration
Treatment
Tourettes
When Diagnosed
Duration
Treatment
Landau-Kleffner Syndrome
When Diagnosed
Duration
Treatment
Other
When Diagnosed
Duration
Treatment
Psychiatric Disorders & Treatments for Child
Please check all that apply and fill in as needed
Mood disorders (bipolar, etc)
Depression
Aggressive/self injurious behavior
Obsessive/compulsive
Anxiety Disorder
Eating/Body Disorder
Addiction
Sleep Disorders
Sensory Integration Disorder
Others
Mood disorders (bipolar, etc)
When Diagnosed
Duration
Treatment
Depression
When Diagnosed
Duration
Treatment
Aggressive/self injurious behavior
When Diagnosed
Duration
Treatment
Obsessive/compulsive
When Diagnosed
Duration
Treatment
Anxiety Disorder
When Diagnosed
Duration
Treatment
Eating/Body Disorder
When Diagnosed
Duration
Treatment
Addiction
When Diagnosed
Duration
Treatment
Sleep Disorders
When Diagnosed
Duration
Treatment
Sensory Integration Disorders
When Diagnosed
Duration
Treatment
Others
When Diagnosed
Duration
Treatment
Learning and Attention Disorders for Child
Please check all that apply and fill in as needed
ADD/ADHD
Learning Disability
Dysgraphia
Dyslexia
Dyscalculia
Other
ADD/ADHD
When Diagnosed
Duration
Treatment
Learning Disability
When Diagnosed
Duration
Treatment
Dysgraphia
When Diagnosed
Duration
Treatment
Dyslexia
When Diagnosed
Duration
Treatment
Dyscalculia
When Diagnosed
Duration
Treatment
Other
When Diagnosed
Duration
Treatment
Social Developmental Disorders for Child
Please check all that apply and fill in as needed
Pervasive Developmental Disorder (PDD)
Autism
Asperger syndrome
Hyperlexia
Other
Other social developmental disorders
(please list)
Age at diagnosis
Who made diagnosis
Developmental pediatrician
Pediatric neurologist
Neurologist
Psychiatrist
Psychologist
Other (please specify)
Who made diagnosis (other)
Behavioral and Educational Treatments for Child
Please check all that apply and fill in as needed
Resource room
Inclusion classes
Accommodations
Special education
Speech therapy
Physical therapy
Occupational therapy
Applied Behavioral Analysis (ABA)
Reading or writing assistance
Assistance in study skills
Assistance in mathematics
Assistance in social skills
Resource room
Start and Length of Treatment, and Intensity of Treatment
Inclusion classes
Start and Length of Treatment, and Intensity of Treatment
Accommodations
Start and Length of Treatment, and Intensity of Treatment
Special education
Start and Length of Treatment, and Intensity of Treatment
Speech therapy
Start and Length of Treatment, and Intensity of Treatment
Physical therapy
Start and Length of Treatment, and Intensity of Treatment
Occupational therapy
Start and Length of Treatment, and Intensity of Treatment
Applied Behavioral Analysis (ABA)
Start and Length of Treatment, and Intensity of Treatment
Reading or writing assistance
Start and Length of Treatment, and Intensity of Treatment
Assistance in study skills
Start and Length of Treatment, and Intensity of Treatment
Assistance in mathematics
Start and Length of Treatment, and Intensity of Treatment
Assistance in social skills
Start and Length of Treatment, and Intensity of Treatment
Infectious Diseases & Treatments for Child
Please check all that apply and fill in as needed
Strep Throat
Sore Throats
Ear Infections
RSV
Mold
Lyme
Other
Strep Throat
When Diagnosed
Duration
Treatment
Sore Throats
When Diagnosed
Duration
Treatment
Ear Infections
When Diagnosed
Duration
Treatment
RSV
When Diagnosed
Duration
Treatment
Mold
When Diagnosed
Duration
Treatment
Lyme
When Diagnosed
Duration
Treatment
Other Infectious Diseases & Treatments
When Diagnosed
Duration
Treatment
Gastrointestinal Diseases & Treatments for Child
Chronic constipation
Chronic diarrhea
Reflux/Coli
Food Intolerance
Eosinophilic esophagitis
Dysbiosis/bacterial overgrowth
Lymphoid Nodular Hyperplasia
Celiac Disease
Enterocolitis/inflammatio
Ulcers
Ulcerative Colitis/Crohn's
Others
Please check all that apply and fill in as needed
Chronic constipation
When Diagnosed
Duration
Treatment
Chronic diarrhea
When Diagnosed
Duration
Treatment
Reflux/Coli
When Diagnosed
Duration
Treatment
Food Intolerance
When Diagnosed
Duration
Treatment
Eosinophilic esophagitis
When Diagnosed
Duration
Treatment
Dysbiosis/bacterial overgrowth
When Diagnosed
Duration
Treatment
Lymphoid Nodular Hyperplasia
When Diagnosed
Duration
Treatment
Celiac Disease
When Diagnosed
Duration
Treatment
Enterocolitis/inflammatio
When Diagnosed
Duration
Treatment
Ulcers
When Diagnosed
Duration
Treatment
Ulcerative Colitis/Crohn's
When Diagnosed
Duration
Treatment
Other Gastrointestinal Diseases & Treatments
When Diagnosed
Duration
Treatment
Immune Disorders & Treatments for Child
Please check all that apply and fill in as needed
Immunoglobulin Deficiency
ANA (+)
Thyroid Autoantibodies
Brain Endothelial Antibodies
PANDAS/Strep Autoantibodies
Folate Transporter Autoantibodies
CAM Kinase
Others
Immunoglobulin Deficiency
When Diagnosed
Duration
Treatment
Type of Immunoglobulin Deficiency
IgA
IgG
IgM
IgE
ANA (+)
When Diagnosed
Duration
Treatment
Thyroid Autoantibodies
When Diagnosed
Duration
Treatment
Brain Endothelial Antibodies
When Diagnosed
Duration
Treatment
PANDAS/Strep Autoantibodies
When Diagnosed
Duration
Treatment
Folate Transporter Autoantibodies
When Diagnosed
Duration
Treatment
CAM Kinase
When Diagnosed
Duration
Treatment
Other Immune Disorders & Treatments
When Diagnosed
Duration
Treatment
Miscellaneous Disorders & Treatments for Child
Please check all that apply and fill in as needed
Growth Failure
Failure to Thrive
Accelerated Growth
Hearing Loss
Visual Loss
Cardiovascular Disease
Kidney Disorder
Blood Disorder
Mitochondrial Disorder
Chronic Abdominal Pain
Cancer
Diabetes
Genetic Disorder
Sickle Cell Anemia
Thyroid Disease
Incontinence
Obesity
Others
Growth Failure
When Diagnosed
Duration
Treatment
Failure to Thrive
When Diagnosed
Duration
Treatment
Accelerated Growth
When Diagnosed
Duration
Treatment
Hearing Loss
When Diagnosed
Duration
Treatment
Visual Loss
When Diagnosed
Duration
Treatment
Cardiovascular Disease
When Diagnosed
Duration
Treatment
Kidney Disorder
When Diagnosed
Duration
Treatment
Blood Disorder
When Diagnosed
Duration
Treatment
Mitochondrial Disorder
When Diagnosed
Duration
Treatment
Chronic Abdominal Pain
When Diagnosed
Duration
Treatment
Cancer
When Diagnosed
Duration
Treatment
Diabetes
When Diagnosed
Duration
Treatment
Genetic Disorder
When Diagnosed
Duration
Treatment
Sickle Cell Anemia
When Diagnosed
Duration
Treatment
Thyroid Disease
When Diagnosed
Duration
Treatment
Incontinence
When Diagnosed
Duration
Treatment
Obesity
When Diagnosed
Duration
Treatment
Other Miscellaneous Disorders & Treatments
When Diagnosed
Duration
Treatment
Past Surgical History for Child
Please check all that apply and fill in as needed
Tonsils/Adenoids
Ear Tubes
Appendix
Hernia
Circumcision
Others
Tonsils/Adenoids
When Performed
Reasons
Complications
Ear Tubes
When Performed
Reasons
Complications
Appendix
When Performed
Reasons
Complications
Hernia
When Performed
Reasons
Complications
Circumcision
When Performed
Reasons
Complications
Other Past Surgical History
When Performed
Reasons
Complications
Any complications of anesthesia?
Yes
No
Please explain
Family History
Check all the sleep disorders in the child’s biological family
Insomnia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Snoring
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Sleep Apnea
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Restless Leg Syndrome
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Periodic Limb Movement
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Sleep Walking / Terrors
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Narcolepsy
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Sleep Disorder
Check all the developmental disorders in the child’s biological family
Speech delay
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Gross motor delay
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Fine motor delay
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Global developmenta delay
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Mental retardation
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Low IQ
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Developmental Disorder
Check all the social developmental disorders in the child’s biological family
Autism
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Asperger syndrome
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Pervasive Developmental Disorder (PDD)
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Social Developmental Disorder
Check all the neurological disorders in the child’s biological family
Epilepsy / Seizures
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Febrile Seizures
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Migraine Headaches
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Chronic Headaches
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Tic disorder
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
PANDAS/PANS
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
PITANDS
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Tourette syndrome
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Cerebral palsy
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
SIDS
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Neurological Disorders
Check all the infectious disorders in the child’s biological family
Recurrent sore throats
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Recurrent strep throats
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Recurrent ear infections
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Infectious Disorder
Family History (Continued)
Check all the learning and attention disorders in the child’s biological family
Learning Disability
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Dyslexia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Dysgraphia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Dyscalculia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
ADHD
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
ADD (without hyperactivity)
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Learning and Attention Disorders
Check all the gastrointestinal disorders in the child’s biological family
Chronic diarrhea
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Chronic constipation
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Gastro-esophageal reflux
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Food intolerance
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Irritable bowel syndrome
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Ulcers
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Celiac disease
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Ulcerative colitis
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Crohn's disease
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Gastrointestinal Disorders
Check all the psychiatric disorders in the child's biological family
Mood disorder
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Depression
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Aggressive / self-injurious behavior
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Obsessive compulsive disorder (OCD)
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Anxiety disorder
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Alcoholism
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Bipolar disorder
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Schizophrenia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Psychiatric Disorders
Check all the inflammatory disorders in the child’s biological family
Allergies
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Asthma
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Psoriasis
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Hashimoto's thyroiditis
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Lupus
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Rheumatoid arthritis
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Autoimmune disorder
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other Inflammatory Disorders
Check all the other disorders in the child’s biological family
Hypothyroidism
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Chronic abdominal pain
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Chronic fatigue syndrome
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Fibromyalgia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Bulimia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Anorexia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Breast cancer
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Cancer, other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Diabetes
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Genetic disorder
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Hypertension
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Blood clots
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Anemia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Sickle-cell anemia
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Alzheimer's disease
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Parkinson disorder
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Prematurity
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Neural tube defects
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Multiple miscarriages
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other
Mom
Dad
Sibling
Mom's parents
Dad's parents
Mom's siblings
Dad's siblings
Maternal cousin
Paternal cousin
Other disorders
Social History
Stress/coping (Please explain if yes)
Has your child experienced any major life changes that may have impacted his/her health?
Yes
No
Please explain any major life changes
Has your child experienced any major losses?
Yes
No
Please explain any major losses
Have you ever sought counseling for your child?
Yes
No
Please explain any counseling
Does your child have a favorite toy or object?
Yes
No
Please explain any favorite toy/object
Does your child practice stress relief practices?
Yes
No
Please explain any stress relief practices
Has your child ever been abused, a victim of crime or experienced a significant trauma?
Yes
No
Please explain any previous abuse/crime/trauma
Environmental History
Please check all that apply
Mold in Bathroom
Damp Home/cellar
Pest extermination (outside)
Pest extermination (inside)
Forced hot air heat
Water in Basement (where applicable)
Mold visible on exterior of home
Heavily wooded surroundings
Pets (Any type)
Moldy, musty school/daycare
Tobacco smoke
Well water (where applicable)
Old/ dusty carpet or bedding
New, very strong smelling carpet or bedding
Feather/ Down bedding
(Parent) hobbies involving smelting or lead (ammunition loading, stained- glass making, etc)
Use of non-organic pesticides on lawns
Travel abroad or wilderness camping
Cognitive For Child
What are your child's 3 greatest strengths?
What are the 3 main issues that we need to focus on first to help your child?
Functional Status For Child
Expressive Speech
Puts _____ words together.
Has _____ back and forth conversation.
Have stuttering
Has
Does not have
Receptive Understanding
Understands~ _____ % of what people say.
Follows _____ step directions.
Has _____ awareness.
Has _____ memory.
Has _____ auditory processing.
Sleep
Bedtime typically at _____ pm.
Takes _____ minutes to fall asleep.
Wakes at _____ am.
Wakes up at night
Does
Does not
Takes naps
Takes
Does not take
Eye Contact
Eye Contact
Good
Moderate
Poor eye contact
Staring spells
Has
Does not have
Looks at things out of the corner of eyes
Does
Does not
Self-Stimulatory Behaviors
Self-Stimulatory Behaviors
Please check all that apply
flapping hands.
finger flicking.
spinning objects.
scripting/repeating lines and phrases.
echolalia.
verbal stimming. grinding teeth.
toe walking.
jumping up and down.
rocking back and forth.
pacing back and forth.
clapping hands.
air writing.
Laughs inappropriately/for no reason.
Does
Does not
An elopement risk
Is
Is not
Sensory Problems
Problems with texture
Has
Does not have
Problems with sounds
Has
Does not have
What is tolerance for pain?
High
Normal
Low
Obsessive Behaviors
Obsessive behaviors
Has
Does not have
Lines up toys
Does
Does not
Fluctuating of obsessive behaviors
Has
Does not have
Related to the gastrointestinal system
Is
Is not
Related to infections
Is
Is not
Mood
Mood
Choose all that apply
moodiness/irritability
defiance/disobedience
frustration easily
anxiety
fears
Transitions
easily
normal
poorly
Tantrums/meltdowns
Tantrums/meltdowns
Has frequently
Has occasionally
Happens rarely
Tics
Tics/involuntary movements
Has
Does not have
Attention
Has what type of attention span?
Good
Moderate
Poor
Energy Level
Energy Level
hyperactivity
impulsivity
heat intolerance
sweating
exercise intolerance
Fatigues easily?
Yes
No
Social Interaction
Interaction with other children
Has
Does not have
Approach other children
Does
Does not
Engages in parallel play
Yes
No
Understands facial expressions/emotions
Yes
No
Understands social cues
Does
Does not
Understands personal space
Does
Does not
Self-Injurious Behavior
Bangs head
Does
Does not
Bites self
Does
Does not
Hits self
Does
Does not
Aggressive Behaviors
Aggressive Behaviors
Hits
Bites
None
Other behaviors
Other aggressive behaviors
Gastrointestinal
Bowel movements are
loose
normal
firm
hard
Color of stool
Color of stool
Bowel movements smell bad/foul.
Bad breath.
Blood in the stool.
Mucus in the stool.
Undigested food in the stool. Abdominal distension/bloating. Gas
Potty-trained.
Abdominal pain.
Posturing or pressing on abdomen. Stool float
Please choose the following as applies
Muscle Tone
Muscle Tone
None
Good
Low (Hypotonia)
Increased (Hypertonia)
Handedness
Handedness
(left handed, right handed)
Fine Motor Skills
Use of utensils
poor
moderate
good
excellent
Handwriting/Coloring Skills
poor
moderate
good
excellent
Do buttons on a shirt
Can
Cannot
Can use scissors appropriately
Can
Cannot
Can tie shoelaces
Can
Cannot
Can pull zipper
Can
Cannot
Gross Motor Skills
Runs
Yes
No
Jumps
Yes
No
Rides bike well
Does
Does not
Goes up and down stairs
With help
Independently
Throw a ball
Can
Cannot
Catch a ball
Can
Cannot
Clumsy/uncoordinated
Is
Is not
Motor planning
Poor
Moderate
Good
Excellent
Therapies
ABA therapy
hrs/week
Speech therapy
hrs/week
Occupational therapy
hrs/week
Physical therapy
hrs/week
School
School
None
Home
Private
Public
Classroom type
None
Special Ed
Mainstream
Has 1:1 Aide
Yes
No
Habits
Complementary Therapies and Treatment for Child (including supplements
Alternative Therapies and Treatments
Press the plus button at the end of each row to create a new row
Treatment
Dose
Duration
Positive Effects
Adverse Effects
Add
Remove
Diet
Diet
Choose all that apply
Allergy/Elimination diet
Atkins diet
Blood type diet
Feingold Diet
FODMAPS diet
GAPS diet
Gluten-free and casein-free (GF/CF) diet
Juicing
Ketogenic diet
Low carbohydrate diet
Low histamine diet
Low pectin diet
Low phenol diet
Low Yeast diet
Mediterranean diet
Modified Atkins diet
Paleo or Caveman diet
Raw Foods diet
SCD diet
Soy free diet
Vegan/Vegetarian diet
Allergy/Elimination diet
Current
Past
Improvements with diet?
Yes
No
Atkins diet
Current
Past
Improvements with diet?
Yes
No
Blood type diet
Current
Past
Improvements with diet?
Yes
No
Feingold diet
Current
Past
Improvements with diet?
Yes
No
FODMAPS diet
Current
Past
Improvements with diet?
Yes
No
GAPS diet
Current
Past
Improvements with diet?
Yes
No
Gluten-free and casein-free (GF/CF) diet
Current
Past
Improvements with diet?
Yes
No
Juicing diet
Current
Past
Improvements with diet?
Yes
No
Ketogenic diet
Current
Past
Improvements with diet?
Yes
No
Low carbohydrate diet
Current
Past
Improvements with diet?
Yes
No
Low histamine diet
Current
Past
Improvements with diet?
Yes
No
Low pectin diet
Current
Past
Improvements with diet?
Yes
No
Low phenol diet
Current
Past
Improvements with diet?
Yes
No
Low Yeast diet
Current
Past
Improvements with diet?
Yes
No
Mediterranean diet
Current
Past
Improvements with diet?
Yes
No
Modified Atkins diet
Current
Past
Improvements with diet?
Yes
No
Paleo or Caveman diet
Current
Past
Improvements with diet?
Yes
No
Raw Foods diet
Current
Past
Improvements with diet?
Yes
No
SCD diet
Current
Past
Improvements with diet?
Yes
No
Soy free diet
Current
Past
Improvements with diet?
Yes
No
Vegan/Vegetarian diet
Current
Past
Improvements with diet?
Yes
No
Dietary infractions caused problems
Please explain
Can swallow pills
Yes
No
Chews on non-food items
Yes
No
Excessive carbohydrate intake
Yes
No
Pica (eating non-food items)
Yes
No
Trouble gaining weight
Yes
No
Does your child naturally avoid certain kinds of foods?
Yes
No
Which foods?
If your child could only eat a few foods daily, what would they be?
Who does the shopping in your household?
Who does the cooking in your household?
How many meals per week does your child eat out?
0-1
2-3
3-5
> 5 meals/week
Please check all that apply to your child’s current lifestyle and eating habits:
Fast Eater
Picky eater
Erratic eating patterns
Limited variety of foods < 5/day
Eat too much
Prefers cold food
Dislike healthy foods
Prefers hot food
Time constraints
Every meal is a struggle
Eat > 50% meals away from home Most family meals eaten together
Poor snack choices
Use food as bribe/reward
Sensory issues related to foods
Erratic mealtimes
Most meals eaten away from table High sugar/sweets intake
High juice intake
Drinks soda/diet soda
Low fruit/vegetable intake
Cow milk (# servings/day)
Caffeine intake
TV/ Videos with meals
Exercise
How many hours/day does your child spend in “screen-time”?
>5
2-5
<2
None
What physical activities does your child do on a regular basis? What do they like to do for fun?
Medications / Supplements
PRESCRIPTION MEDICINES (PLEASE LIST WITH STRENGTHS AND DOSES)
Please use the plus icon at the end of each row to add additional rows
Add
Remove
OVER-THE-COUNTER MEDICINES (PLEASE LIST WITH STRENGTHS AND DOSES)
Please use the plus icon at the end of each row to add additional rows
Add
Remove
List nutritional supplements
Please use the plus icon at the end of each row to add additional rows
Add
Remove
Vaccine History
Vaccine History
Never Vaccinated
Partially Vaccinated
Fully Vaccinated per CDC Recommendations
Reason for never/partially vaccinated
Any problems noted with vaccines?
Please briefly explain
Review of Systems
Strengths
Accepts new clothes
Cuddly
Physically coordinated
Happy
Pleasant/easy to care for Sensitive/affectionate
Wants to be liked
Responsible
Draws accurate pictures
Sensitive to people’s feelings
OK if parents leave
Answers parent
Follows instructions
Pronounces words well
Unusual memory
Excellent math/computer skills
Bold, free of fear
Likes to be held/swaddled
Sleep
Sleeps in own bed
Sleeps with parents
Awakens screaming/crying
Awakens at night
Difficulty falling asleep
Early waking
Insomnia
Sleeps less than normal
Daytime sleepiness
Jerks during sleep
Nightmares
Sleeps more than normal
Physical
Looks sick
Glazed look
Overweight
Underweight
Pupils unusually large
Pupils unusually small
Dark circles under eyes
Red lips
Red fingers/Toes
Webbed toes
Red ears
Double jointed
High arched palate
Lymph nodes in neck always swollen Head warm/always sweaty
Abnormal fatigue
Failure to thrive
Cold all over/hands, feet
Cold intolerance
Hands/feet very sweaty
Night sweats
Odd smelling sweat, urine
Skin
Very Pale
Fungus on finger/toenails
Dandruff
Chicken Skin
Oily skin
Patchy dullness
Seborrhea on face
Thick calluses
Athlete’s foot
Smelly feet
Diaper rashes frequently
Odd body odor
Acne
Eczema
Very sensitive to bug bites
Stretch marks
Blotchy skin
Cradle cap
Dry/brittle hair and scalp
Bites nails
Nails frayed, pitted, brittle or soft
Easy bruising
Birth marks
Thickened toe/fingernails
Vitiligo
White spots/lines in nails
Dry skin in general
Lower legs dry
Skin lackluster
Itchy skin (for no known reason)
Itchy Ears or roof of mouth/throat
Itchy Anus
Itchy penis/vagina
Mood
Apathy
Depression
Detached/Disinterested Poor eye contact
Isolated
Negative
Fright without reason
Does not want to be touched Inconsolable crying
Irritable
Looks like in pain
Moaning, groaning
Phobias
Severe mood swings
Unhappy
Agitated
Anxious
Sensory
Bothered by certain sounds
Covers ears with sounds
Ear Pain
Ear ringing
Hearing loss
Sensitive to loud noise
Ringing in ears
Examines by smelling things
Very sensitive to odors
Excessive blinking
Oversensitive to light
Eye crusting/itching
Eyelid margin redness
Fails to blink to bright lights
Likes flickering lights
Looks out of corner of eye
Poor vision
Puts eye to bright light or sun
Crossed eyes
Fearful of harmless objects
Unaware of danger for age
Unaware of people’s feelings
Unaware of self as a person
Easily upset if things change
Adopts complicated rituals
Car/truck or train obsessions
Collects unusual things
Draws only certain things
Fixated on one topic
Lines up objects precisely
Repeats old phrases
Fingertip squeezing
Hates wearing shoes
Insensitive to pain
Like head burrowed or pressed hard
Likes to be held upside down or swung in the air
Digestive
Excessive drooling/salivation
Cracking lip corners
Frequent cold sores
Geographic tongue
Sore tongue
Tongue coated
Frequent cold sores in mouth
Gums bleeding
Tooth grinding
Severe/frequent cavities
Amalgam (Silver) fillings
Oral thrush (yeast/white coating)
Sore throats
Frequent burping
Nausea
Reflux/spitting up
Frequent vomiting
Recurrent abdominal pain
Intestinal parasites
Crampy pain with passing stool
Anal fissures
Red ring around anus
Respiratory
Pneumonia
Bad odor in nose
Breath holding spells Bronchitis/bronchiolitis
Congestion with changing seasons Congestion in Fall
Congestion in Spring
Recurrent cough
Post nasal drip
Runny nose all the time
Sighing
Sinus fullness
Wheezing
Yawning excessively
Watery stool
Yeasty smelling stool
Undigested food particles in stool
Eating
Poor appetite
Excessive thirst or water drinking
Binge eating
Craves juice/sugar
Craves dairy products
PICA (eating non-food items)
Abnormal food cravings
Carbohydrate intolerance
MSG or Artificial sweetener (Aspartame) intolerance
Food coloring intolerance
Lactose intolerance
Behavior worse with certain foods Behavior better when fasting
Behavior
Self- mutilation
Runs away
Climbs to high places
Insists on what is wanted
Tries to control others
Does opposite of what is asked
Teases others/bully
Unusual shrieks
Holds hands in strange position Spends time in pointless tasks
Stares at own hands
Toe walking
Arched back with bright lights
Reproductive
Girls: early 1st period
Boys: Large testicles
Early breast development
Early pubic hair
Delayed puberty
Girls: Vaginal odor
Girls: Breast tenderness or fibrocystic lumps
Urinary
Frequent urination
Bed wetting after age 4
Urinary hesitancy
Painful urination
Unusual color or odor to urine
Please list out anything else that you feel is helpful for the doctor to know
Patient or Parent/Guardian First Name
(Required)
Patient or Parent/Guardian Last Name
(Required)
Patient or Parent/Guardian Email
(Required)
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