Psychology/Psychiatry Departments
Patient Questionnaire
Today’s Date _______________________
Your name________________________
Child’s Name _______________________________________________ Gender ______
Birthdate__________
Address ___________________________________________________ Best phone #______________________
Parents’/Guardians’ Name/s_____________________________________________________________________
Parents’ Marital Status ___________ (Married, Divorced, Never Married)
Your Relationship to this Child ________________ Who has custody of this child? ________________________
Siblings’ Names/Ages __________________________________________________________________________
Other persons living in your child’s home___________________________________________________________
What concerns do you have about your child?_______________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
When were you first concerned about these issues?__________________________________________________
Have you previously sought assistance for these concerns? YES ___ NO ___
If YES, what is the name of that therapist? _________________________________________________________
Is your child still receiving services/treatment? YES ___ NO ___
Was the previous treatment helpful?
YES ___ NO ___
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If NO, date of last appointment __________
Psychology/Psychiatry Departments
Patient Questionnaire
DEVELOPMENTAL HISTORY
Were there complications during pregnancy or the delivery of your child?
YES ___ NO ___
Did the mother require any medications during pregnancy?
YES ___
NO __
At what age did your child:
Roll Over __________
Crawl
Walk
Combine words __________
__________
__________
Use single words
__________
Become toilet trained __________
Do you have concerns about any of the following for your child?
Health issues?............................................................................................................
Yes No
Use of words (speaking ability, size of vocabulary, rarely speaks, etc.)?..................
Yes No
Understanding of what others say (hearing abilities, comprehension level, or
attention span)?........................................................................................................
Yes No
Sleep patterns?.........................................................................................................
Yes No
Trouble falling asleep?..............................................................................................
Yes No
Night time wetting?..................................................................................................
Yes No
Daytime wetting?......................................................................................................
Yes No
Bowel accidents?.......................................................................................................
Yes No
Appetite?..................................................................................................................
Yes No
Getting alone with others?.......................................................................................
Yes No
Behavior problems?..................................................................................................
Yes No
Recent changes or family stressors (e.g., divorce, separation, loss of a loved one,
loss of pet, family illness, parental job loss, trauma or abuse)?...............................
Yes No
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Psychology/Psychiatry Departments
Patient Questionnaire
If you answered “Yes” to any of the above, please explain_______________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
School
Child’s grade in school ____________ Name of school currently attending______________________________
What grades does your child earn?
Above Average (A’s or B’s) _____
Average (C’s) _____
Has your child ever repeated a grade in school?
Below Average (D’s or F’s) ______
YES ___
NO ___ If YES, which grade? ______________
Does your child receive any educational interventions? YES ___
NO ___ If YES, what are they? ____________
___________________________________________________________________________________________
___________________________________________________________________________________________
Does your child have an Individual Educational Plan?
YES ___
NO ___
If YES, please bring a copy of the IEP to your first visit.
Please describe your child’s strengths, hobbies and interests. _____________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Psychology/Psychiatry Departments
Patient Questionnaire
Medications your child takes
Medication
Dose
How Often
_________________________________________ _____________
______________________
_________________________________________ _____________
______________________
_________________________________________ _____________
______________________
_________________________________________ _____________
______________________
_________________________________________ _____________
______________________
Previous Medications
Dose
How Often
_________________________________________ _____________
_______________________
_________________________________________ _____________
_______________________
__________________________________________ _____________ _______________________
Insurance Information
Is your child covered by commercial insurance or Medicaid? YES ___
NO ___
Name of insurance plan ___________________________________ Policy # __________________________
Name of insurance subscriber on this plan? ___________________ Relationship to the child? ________________
Is this child covered by a 2nd insurance plan or Medicaid?
YES ___
NO ___
Name of 2nd Insurance plan _________________________________ Policy # _________________________
Name of insurance subscriber on this plan? ____________________ Relationship to the child? _______________
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Psychology/Psychiatry Departments
Patient Questionnaire
Contact Information
What is the best phone number to reach a parent/legal guardian to schedule this appointment?
Phone number _______________________
(Circle: Home/Work/Cell)
Parent/Guardian name _________________________________
Please return this form to the address or fax listed below. Thank you for helping us better understand your
concerns and we look forward to providing services to your family.
If you have any questions, please contact us at 937-641-3401. We will call you within three days of the receipt of this
form to schedule an appointment.
Mailing Address
Dayton Children’s
Psychology/Psychiatry Departments
One Children’s Plaza
Dayton, OH 45404
or
Fax Number
937-641-3066
Dayton Children’s
Attn: Psychology/Psychiatry Department
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