Patient Symptom Checklist Page 4
ADVERTISEMENT
1
2
3
4Substance Use
Age at first
Date of
Frequency:
Amount Used
Use
last Use
Daily, Weekly,
Monthly,
Occasional
Drinks alcohol
Smokes marijuana
Use amphetamines (speed, ice, crank, etc…)
Uses cocaine or crack
Uses inhalants (sniffs glue, paint, air freshener, gasoline,
markers, etc…)
Uses ecstasy
Uses hallucinogens (LSD, mushrooms, heroin, etc…)
Uses sedatives (Valium, Xanax, Ativan, etc…)
Uses painkillers (Vicodin, Oxycontin, Soma,
hydrocodone, etc…)
Uses PCP
Abuses prescription drugs
If yes, what?
Uses tobacco
If yes, what form?
Family use of Alcohol/Illegal Drugs in Home:
Yes______________No____________
Who/Type_____________________________________________________________________________
History of blackouts or withdrawal symptoms______________________________________________
DEVELOPMENTAL ISSUES
Normal pregnancy and delivery?______________________________________________________________
Difficulties at birth________________________________________________________________________
Mother use of drugs or alcohol during pregnancy___________________________________________________
Birth weight_____________________________________________________________________________
Able to soothe as an infant___________________________________________________________________
Approximate Age:
Slept all night_____ Crawled _______Walked __________Talked ____________________
Child’s Special Interests/Hobbies_____________________________________________________________
Clubs/School Activities___________________________________________________________________
Child’s Goals for Self______________________________________________________________________
Child Friendship Pattern:
Makes friends easily_____
Can not maintain friends___________ No friends, socially isolated_____________
History of bullying____________________Type________________________________________________
Special Family Issues That May be Affecting Your Child_______________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
Completed by____________________________________Relationship to child____________________
THE EXCEL CENTER
PATIENT NAME
PATIENT SYMPTOM PARENT REPORT
12/12 pdexcelforms
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life