Adolescent Psychosocial Assessment Form Page 2
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4CLIENT NAME:_____________________________
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EDUCATION/EMPLOYMENT HISTORY:
Current school(s) _______________________________________ Grade level _______________________________
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What are your current grades?
A’s
B’s
C’s
D’s
E’s
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Are there any school attendance issues?
Yes
No If yes, explain.____________________________________
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Have you ever had speech and language therapy?
No
Yes, where and when?___________________________
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______________________________________________________________________________________________
Check all that apply regarding your school experience:
gifted classes
special education
school suspensions
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problems with classmates/bullying
problems with teachers
cheating
extracurricular activities
Do you have any learning problems?
Yes
No
If yes, what are the problems? ______________________
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______________________________________________________________________________________________
Do you have a job?
Yes
No If yes, what is your job?____________________________________________
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Do you have any other sources of income? If yes, please list.
Yes
No_________________________________
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Do you have any current job issues?
Yes
No
_______________________________________________
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Do you have problems with focus or attentiveness?
Yes
No
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Do you have problems staying seated?
Yes
No
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DEVELOPMENTAL/MEDICAL HISTORY:
Length of Mother’s pregnancy for you?
premature
full-term
post-term Birth weight_____________
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Were there any complications during pregnancy and/or during/after birth? (ie. Jaundice, head injury, etc)___________
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______________________________________________________________________________________________
Did your Mother use substances during pregnancy?
Yes
No If yes, please list. ___________________
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Developmental Milestones (please list age when accomplished)? Crawl ______ Walk _______ Single word _____
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2 words+ _____ Bladder trained? day_____ night______ Bowel trained? day______ night________
Has there been a history of bedwetting?
Yes
No If yes, explain; ____________________________________
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Has there been a history of soiling?
Yes
No If yes, explain; _______________________________________
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Hearing issues?
Yes
No
If yes, explain_____________________________________________________
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Vision issues?
Yes
No
If yes, explain_____________________________________________________
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Dental issues?
Yes
No
If yes, explain_____________________________________________________
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Medical Primary Care Physician: ________________________________________ Date last seen: _____________
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How do you rate your general health?
poor
fair
average
good
excellent
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Immunizations up to date?
Yes
No
If no, explain?____________________________________________
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What, if any, medical problems do you have (such as asthma, diabetes)?____________________________________
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______________________________________________________________________________________________
Are you currently taking medications?
Yes
No
If yes, what medications?__________________________
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______________________________________________________________________________________________
Drug allergies/adverse reactions/side effects___________________________________________________________
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_______________________________________________________________________________________
Do you have any concerns related to your weight?______________________________________________________
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Has your weight change over the last year?
No
Yes
Lost _____lbs.
Gained _____lbs.
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How many meals do you eat a day?_______Do you have any changes in eating habits/appetite?
Yes
No
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If yes, please describe: ____________________________________________________________________________
Do you currently participate in any type of exercise/physical activity? If yes, please describe: ___________________
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______________________________________________________________________________________________
Caffeine Use: How many cups, cans or glasses of caffeinated beverages per day do you drink? __________________
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Do you currently use any tobacco products? If yes, describe_______________________________________________
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Have you had any head injuries or loss of consciousness?
Yes
No
If yes, explain:___________________
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_______________________________________________________________________________________
Have you had any surgeries?
Yes
No
If yes, please list dates and what type:________________________
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_______________________________________________________________________________________
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