Attachment 11a - Child'S Medical, Medication, And Prenatal History - Riverside County Department Of Mental Health
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R i v e r s i d e C o u n t y D e p a r t m e n t o f M e n t a l H e a l t h
C H I L D ’ S M E D I C A L , M E D I C A T I O N , A N D P R E N A T A L H I S T O R Y
CHILD’S NAME: ___________________________________________________ SS#: _______________________________
AGE: __________
DATE OF BIRTH: _________________________
DATE: _____________________________
In order to provide the best mental health care, it is necessary to know some things about your child’s physical condition. Please
answer the following questions as best you can. Someone will assist you if necessary.
MEDICAL:
HAS YOUR CHILD EVER HAD: (Please write in “yes” or “no” next to each question)
Ear, nose, and throat problems? _______ Frequent colds? _______
Frequent earaches? _______
Other? __________________________________________________________________________________________________
Eye problems?
Infections? _______
Wears glasses? _______
Other? _____________________________________
Stomach or intestinal problems? _______
Frequent stomachaches? _______ Vomiting? _______ Diarrhea? _______
Soiling? _______
Lung problems?
Cough? _______
Asthma? _______
Pneumonia? _______
High fevers?__________
Convulsions? _______
Heart problems?
“Blue Baby”? _______
Other? __________________________________________________________
Urinary problems? Bladder infection? _______
Persistent wetting? _______
Other? __________________________________________________________________________________________________
Allergies? _______
Sneezing, always runny nose? _______ Itching? ________ Food or medication sensitivity? __________
Other? __________________________________________________________________________________________________
Surgery? ________________________________________________________________________________________________
Injury? (Including head injury) _______ Near drowning? _______
Poisoning? _______
Other? __________________________________________________________________________________________________
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Is child under a doctor’s care regularly (except for routine physical, immunization, occasional illness)? _________________________
Does your child need to see a doctor for physical problems? _______
Please give a short explanation of questions answered “yes.”
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Confidential Patient Information. See California & Institutions Code 5328
February 2012
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