

PARENT QUESTIONNAIRE 1. Does your child have problems with the following? ¸ Place a check by any that apply to your child. (Please ask if you have any questions) a. Anger control in school _____ b. Anger control at home _____ c. Oppositional behavior at home _____ d. Oppositional behavior in school _____ e. Hyperactivity (too much energy, can't sit still) _____ f. Inattention (refuses to do things that are boring like homework) _____ g. Poor grades in school _____ Since what grade? _________________________________________ For what reasons? ______________________________________________________ ______________________________________________________ h. Hears voices or other things that no one else can hear _____ i. Depression or sadness _____ j. Multiple school suspensions, detentions, or calls home _____ For what reasons? ______________________________________________________ ______________________________________________________ ______________________________________________________ Since which grade? ______________________________________________________ ______________________________________________________ k. Slow learner _____ l. Refuses to do chores _____ m. Nervousness, anxiety, fear, or panic _____ n. Strange or bazaar behavior or thoughts _____ Please describe: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ o. Bed wetting _____ p. Bowel control _____ q. Drug or alcohol use _____ What types ______________________________________________________________________________________ r. Stay up all night then not feel tired the next day nor sleep late the next Morning? ______ 2. Please describe the problems you are seeking help with for your child: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ 3. Does your child have any medical conditions or illnesses? ______________________________________________________ ______________________________________________________ ______________________________________________________ 4. During pregnancy or delivery, were there any problems? ______________________________________________________ ______________________________________________________ ______________________________________________________ 5. Was there any drug or alcohol use during pregnancy? Yes ____ No____ cocaine _____ marijuana _____ alcohol _____ Prescribed medications _____________________________________ Other ______________________________________________________ 6. Did or do any family members that the child is related to by blood have any of the following mental conditions? If so, please state Yes and how that person is related to the child. Please include all relatives on mom?s and dad?s side (parents, siblings, cousins, aunts, uncles, great grandparents, etc?). a. Hear voices ______________________________________________________ b. Anger/temper problems ______________________________________________________ c. Drug or alcohol problems ______________________________________________________ d. Anxiety, panic or depression ______________________________________________________ e. Bipolar disorder or manic/depression ______________________________________________________ f. Hyperactivity or inattention ______________________________________________________ g. Slow learner ______________________________________________________ h. Nervous breakdowns ______________________________________________________ i. Other: ______________________________________________________ Do you know the biological father?s family mental health history? Yes___ No ___ Some ____ Do you know the biological mother?s family mental health history? Yes ___ No ___ Some ____ Mitchell L. Glaser, MD. 7. Is your child in special education? Yes___ No___ 8. At what age did your child walk without any help? ____________ Speak single words (such as mom or milk)? _______________ 9. Please list all current medications your child is taking: ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ 10. Please list all previous psychiatric medications your child has taken and how each affected him/her. Also if known, from when to when and how many miligrams. ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ 11. Please list all previous psychiatric hospitalizations, include when (age or year), and why (such as anger or ran away or sadness or suicide attempt etc?) ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ 12. Please describe any physical, sexual, or emotional traumas that your child has experienced or witnessed and when it occurred. _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ ________________________________________________________ ________________________________________________________ 13. How are you related to the child? (parent, aunt, grandmother, adopted parent, biological parent, caseworker, etc?) _________________________ ______________________________________________________ ______________________________________________________ 13b. Does the child know how he/she is related to you (or your spouse)? ___________________________________________ 14. Who currently raises the child and who lives in the household: ______________________________________________________ ______________________________________________________ 15. Who has previously raised the child or in how many different foster homes has the child lived? ______________________________________________________ ______________________________________________________ ______________________________________________________ 16. If you are the biological or adopted parent(s) please list your current type of employment(s) and your level(s) of education. _____________________________________________________ ______________________________________________________ Mitchell L Glaser, MD. Sundeep Randhawa, MD.

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