New Pediatric Psychiatry Patient Intake
Child's Name
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Form completed by
Age of chid
Sex assigned at birth
Gender identity and pronouns
Briefly state your concerns about this child?
Has your child been seen by any other persons for this problem? Any previous hospitalizations or suicide attempts. Any current suicidal/homicidal thoughts?
0/20
Have there been any concerns about your child's development?
Complications of pregnancy or birth?
Were they born at term or early?
During pregnancy did mother use: Tobacco, Alcohol, or other substances in pregnancy? If yes please explain
Describe any problem behaviors or personality difficulties as a preschooler
Has your child had any traumatic or potentially traumatic experiences? If so, briefly explain:
Have there been recent significant changes in your child's life?
Have there been prior events or changes, such as divorce, death of a loved one?
Have you had prior legal problems in any way associated with your seeking treatment for your child at this time? Please explain if yes:
Name of your child's primary care doctor
Phone
Format: (000) 000-0000.
Date of your child's last physical examination
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Height
Weight
Does your child have any serious illnesses or medical conditions?
Has your child had any surgeries or hospitalized? Please list dates with any surgeries.
Is your child allergic to food or medication? If yes, explain
Please list any current medications including dosages and frequency
Does your family identify with particular cultural or ethnic groups? Of what overall importance is this in your family's life?
How much time does your child spend on play and leisure on a typical week day?
Weekend day?
TV hours per day
Computer/phones hours per day
Format: (000) 000-0000.
Video game hours per day
Current grade
Name of school
What is your child's attitude about school? Teachers? Other students?
Any concerns about school? Performance or behavior problems?
Prior schools and duration
Please list any medical and psychiatric conditions in immediate family members such as biological siblings and parents.
Please list all members of this child's household, their relationship to child, ages, and occupation if appropriate.
Name and relationship of any other significant people
Have there been any significant separations, divorces, deaths or other events?
Please list any symptoms the child currently has, including signs of infection, problems with sleep or breathing, body pains or mood symptoms. Dr. Sastry will review details so please only list current symptoms.
If you are aware of any substances your child uses, please list them:
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