Adolescent Psychosocial Asessment Page 5
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14Please list medications (including psychotropic, over‐the‐counter, herbal remedies) that you have taken in the
past 6 months
Reason for
Medication
Dosage
Frequency
Prescribed By
Medication
Is your child taking the medications as prescribed? Yes No If No, please explain: ________________
___________________________________________________________________________________________
Additional information (if needed): ______________________________________________________________
___________________________________________________________________________________________
Has your child ever had a serious accident/illness or hospitalization? Yes No
Please list all past hospitalizations, surgeries, accidents, or illnesses in the chart below.
Reason for Previous Hospitalizations, Accident, Illness
Date/Location of Hospitalization
Has your child had the following screenings (please check all that apply)?
Hearing Screening
Date: _____________________ Outcome: _____________________________________
Vision Screening
Date: _____________________ Outcome: _____________________________________
Speech/Language Screening Date: __________________ Outcome: _________________________________
Primary Care Doctor: _________________________ Facility: ___________________ Phone Number: __________________
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Parent category: Medical