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? ______________________________________________________

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k. Slow learner _____

l. Refuses to do chores _____

m. Nervousness, anxiety, fear, or panic _____

n. Strange or bazaar behavior or thoughts _____

Please describe: ______________________________________________________
______________________________________________________

______________________________________________________

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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:

______________________________________________________

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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:

______________________________________________________

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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.

______________________________________________________

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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?) ______________________________________________________

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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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