Patient Symptom Checklist

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PARENT REPORT OF SYMPTOMS
What are the problems that caused you to seek help at Excel for the child?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
How long have you had these problems with the child?
_______________________________________________________
MENTAL HEALTH TREATMENT HISTORY
OUTPATIENT/INPATIENT OR RESIDENTIAL CARE
DATES
CURRENT PSYCHIATRIST______________________________ TELEPHONE#____________________
CURRENT THERAPIST__________________________________ TELEPHONE #___________________
PAST PSYCHIATRIC MEDICATION HISTORY
MEDICATION
PRESCRIBER
DATES
REASON FOR CHANGE/SIDE EFFECTS
FAMILY MEMBERS MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT HISTORY
RELATIONSHIP
DIAGNOSIS
HOSPITLAIZATIONS MEDICATIONS
Patient raised by__________________________________________________________________________
Patient currently living with__________________________________________________________________
Others in the home________________________________________________________________________
______________________________________________________________________________________
Adopted: Yes ___ No____Age of adoption__________Does child know?_______________________________
Circumstances of adoption___________________________________________________________________
Parents separated_________
Divorced______
Age of child at separation____________________
Custody arrangements______________________________________________________________________
THE EXCEL CENTER
PATIENT NAME
PATIENT SYMPTOM PARENT REPORT
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