Patient History Form Page 4
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7Describe the types of discipline that you have used with your child and how effective they have been: __________
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you participated in a parenting class or obtained other forms of information concerning discipline and
behavior management? ______________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
PEER RELATIONSHIPS
Does your child have problems making/keeping friends? _____________________________________________
Does your child play with other children the same age? ____________________________________________
Younger? _____________________________________ Older? ______________________________________
Briefly describe any problems your child may have with peers. ______________________________________
__________________________________________________________________________________________
How does your child get along with other family members?_________________________________________
__________________________________________________________________________________________
MEDICAL AND DEVELOPMENTAL HISTORY
PREGNANCY
While you were pregnant with this child, were you under a doctor’s care?
Yes
No
Describe any medical, emotional or substance use issues during pregnancy (please include any medications
used during pregnancy). _____________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
BIRTH HISTORY
Mother’s age at time of birth: _______ Father’s age at time of birth: _______
Did mother smoke during pregnancy?
Yes
No
Family Psychology
Drink Alcohol?
Yes
No
Associates
727.725.8820
What did the baby weigh?: ____________
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