Form Dss-5225 - Request For Nc Kids Legal Risk Search - North Carolina Child Welfare Services Page 2
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1
2SPECIAL NEEDS INFORMATION
Must be diagnosed and/or documented in case file. Please check all that apply.
PHYSICAL DISABILITIES cont’d
OVERALL FUNCTIONING
PHYSICAL DISABILITIES
1 = None
2 = Mild
3 = Moderate
4 = Severe
Terminal Illness
None
Physical
Tourette’s Syndrome
Allergies (Specify ________)
Emotional
Total Care Required
Asthma
Learning
Tracheotomy
AIDS
Mental Retardation
Tube Feeding
Blindness/Visual Impairment
Visual Impairment
Cancer
EMOTIONAL DISABILITIES
Other
Cerebral Palsy
Congenital Heart Disease
None
Cystic Fibrosis
Adjustment Disorder
MENTAL RETARDATION
Anxiety Disorder
Deaf/Profound Hearing Loss
None
Anorexia
Developmental Disabilities
Down’s Syndrome
Attachment Disorder
Diabetes
MR - Not specified
Dwarfism
Bi-Polar Disorder
MR - Genetic
Encopresis
Borderline Personality Disorder
Praeder Willi Syndrome
Bulimia
Enuresis
Trisomy 13
Conduct Disorder
Epilepsy
Trisomy 18
Compulsive Lying
Failure to Thrive
William’s Syndrome
Cruelty to Animals
Fetal Alcohol Effects
Other
Fetal Alcohol Syndrome
Depression
HIV Positive
Dysthymia
RISK FACTORS
Fire Starter
Hearing Loss - Partial
None
Inappropriate Masturbation
Heart Defect
Alcohol Exposed
Loss Issues
Heart Murmur
Domestic Violence in Birth Family
Hydrocephalus
Obsessive Compulsive Disorder
Drug Exposed
Hyperactivity
Oppositional Defiant Disorder
HIV Exposed
Physically Aggressive to Adults
Hypertension
Lead Poisoning
Physically Aggressive to Peers
Kidney Disease
Mental Illness in Birth Family
PICA
Macrocephalus
Mental Retardation in Birth Family
Post Traumatic Stress Disorder
Medically Fragile
Neglected
Microcephalus
Property Damage
Physically Abused
Missing Limb(s)
Psychosis
Schizophrenia in Birth Family
Reactive Attachment Disorder
Motor Skills Disorder
Sexually Abused
Run Away
Multiple Sclerosis
Other
Self Abusive
Muscular Dystrophy
Non-Ambulatory
Sexually Acting Out With Peers
Non-Verbal
Sexually Provocative Behavior
Please list all medications this child is
Stealing
On Medication (list on right)
taking:
Takes Psychiatric Medication
Paralysis
Other
Phenylketonuria (PKU)
Premature Birth
LEARNING DISABILITIES
Quadriplegia
Scoliosis
None
Seizure Disorder
Aphasia
Sexually Transmitted Disease
Attention Deficit Disorder
Shaken Baby Syndrome
Attention Deficit Hyperactivity Disorder
Sickle Cell Anemia
Autism
Sickle Cell Trait
Central Auditory Processing Disorder
Speech Disorder
Developmental Articulation Disorder
Spina Bifida
Dyslexia
Expressive Language Disorder
Learning Disability
Non-Specific Learning Disorder
Receptive Language Disability
Other
DSS-5225 (Rev. 8/13)
Page 2 of 2
Child Welfare Services
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