Behavioral Assessment Parent Questionnaire - Advanced Pediatric Associates printable pdf download

ADVANCED PEDIATRIC ASSOCIATES

Behavioral Assessment Questionnaire

Child’s Name: ___________________ DOB: ___________ Age: ________ Today’s Date: ___________

Name of person completing this form: ______________________________Relationship:_____________

In your own words, what is the reason for this visit? __________________________________________

_____________________________________________________________________________________

What help are you seeking from Advanced Pediatrics?_________________________________________

_____________________________________________________________________________________

Is this evaluation for (check all that apply)?:

First-Time Evaluation

Second Opinion

Updated Evaluation

Consider Medication for ______________________

Please list any social workers, therapists, school staff, or other professionals currently involved in the

child’s welfare, or any educational plans in place: ____________________________________________

____________________________________________________________________________________

List any previous developmental, school, or mental health evaluations for the child—when, where,

results: ______________________________________________________________________________

____________________________________________________________________________________

_____________________________________________________________________________________

Is or has your child ever taken any medication for an emotional, behavioral, or mental health problem? If

so, what and when? Include herbal or over-the-counter medication. ______________________________

_____________________________________________________________________________________

Family Medical History

Indicate any relatives of the child with any of the following problems.

Brothers

Natural

Mother’s

Natural

Father’s

Sisters

Mother

Relatives

Father

Relatives

Obsessive-Compulsive disorder or fussy habits,

picky, rigid

Tics or other nervous habits, Tourette’s

Depression for more than 2 weeks, medications for

mood disorder

Suicide or attempted suicide

Psychosis or schizophrenia, hospitalized for mental

or emotional problems

Alcohol or drug abuse

Legal problems, arrests, jail/prison time, court

probations, “always in trouble”

Serious or chronic medical problems: cancer,

deafness, heart problems, seizures, diabetes, etc.

Gambling, shopping or other compulsions

Is there anything else we should know about your child or family?_______________________________

_____________________________________________________________________________________

May 2012

Behavioral Assessment Parent Questionnaire - Advanced Pediatric Associates

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