PAUL FOXMAN, PH.D

Home setting history:

	Start Date	End Date	Location	Reason for Moving	Any Problems?
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2
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5

Residential placements, institutional placements or foster care:

	Start date	End date	Program name	Program location	Reason for placement	Problems?
1
2
3
4
5

School(s):

	Name	District	Address	Phone Number
Current
Previous
Previous
Previous

Please check all that apply:

My child has had learning problems in schoolMy child has had social problems in schoolMy child is receiving special help at school
Any other school related concerns?
Child's current teacher:

First NameLast Name
Phone number:
Please enter a valid phone number.
Email:
example@example.com
May I call or email to discuss your child with their current teacher?

YesNo
What are your concerns about your child?
How long has this difficulty existed?
Have you previously sought help?

YesNo
If yes, when and where?
Do you have any ideas about why your child is having problems now?

Child's health

List all severe illnesses, accidents, operations, handicaps and repeated medical problems (such as ear infections, headaches, etc.) and all other medical conditions:

	Condition	Age	Treated by whom?	Consequences?
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2
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Medications

List all medications, past and present:

	Medication	Date first prescribed	Doctor	Effect
1
2
3
4
5
6

Child's Pediatrician
Pediatrician:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number:
Please enter a valid phone number.
Date of last physical exam:

MonthDayYear
Date
Results:

Child's Developmental History
Have you noticed any problems in development?

YesNo
If yes, describe:
Milestones

At what age did the child demonstrate the skills listed below? Were any of these skills difficult or slow to develop?

	Age	Describe
Sat without support
Crawled
Walked without holding on
Helped when being dressed
Ate with a fork
Stayed dry all day? All night?
Didn't soil pants
Dressed themselves completely
Age first word was spoken
Age first few sentences were spoken
Any speech, hearing or other impediments/delays?
Writing
Reading
Riding a bicycle
Tying shoes

Child's Temperment

Select yes or no and describe when appropriate:

	Yes	No	Describe
Is your child overactive?
Does your child have trouble paying attention?
Does your child have trouble staying with an activity?
Does your child have fluctuating moods?
Does your child get frustrated easily?
Are your child's emotional responses generally unpredictable?
Does it take your child a long time to warm up to new situations/people?
Does your child react strongly to physical pain?
Does your child react strongly to other things?

Have there been any challenges in the following areas?

	Yes	No	Describe
Discipline
Temper or fighting
Moods
Relationship to others
Sex play
Other behaviors

Summary
Please describe your child's strengths:
What are your child's special skills or talents? List hobbies, sports, recreational, TV toy preferences, etc.:
Please feel free to write anything else you think we should know about your child:
This is a strictly confidential patient medical record. Re-disclosure or transfer is expressly prohibited by law.
Should be Empty:

	Yes	No	Describe
Medical problems during pregnancy?
Medications during pregnancy?
Did either parents drink much alcohol during pregnancy?
Birth weight and length?
Was child born premature? If yes, how premature?
Any birth complications or problems?
Problems with newborn period or infancy?
Breast fed? If yes, for how long?
Was or is child allergic to medications, food, etc.?
Sleep patterns or problems?

	Yes	No	Relationship	Describe
Neurological disease (seizures, etc.)
Medical disease (ex. diabetes, thyroid, heart disease)
Emotional conditions
Cognitive or learning delays
Learning problems
Behavior problems
Excessive alcohol use
Excessive drug use
Trouble with the law
Trouble holding down a job
Physical abuse
Sexual abuse
Other

	Yes	No	Explain
Parental separation or divorce
Family moves
Recent deaths or losses (within last 3 years)
Other major family changes
Has anyone in your family seen a psychologist, psychiatrist or mental health care worker?
Any recent changes/stresses in living situation or family?

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
Your present marriage/relationship
Your present work situation
Your present living circumstances

	Symptom	Description	When did this begin?
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Child Information & Developmental History