Child Intake and Consent Form

Date file opened:

C.I.F. No:

Personal Information:

Name

Marital Status

Age

Educational Qualification

Gender

Male
Female
Others

Occupation

Address

Referred by

Socio economic status

Reason for referral

Patient brought to clinic by:

Informant (Name, relationship, intimacy, length of contact, consistency, acquaintance):

Reliability

Adequacy

Presenting Complaints

Duration

Age at which problems were recognised

Onset

Course

Progress

Predisposing factors

Precipitating factors

Perpetuating factors

Total duration of illness

History of Present Illness

Negative History

Past History

Family History

Type of family

Family status

Consanguinity in the family

Specify relation, if present

Household Composition

Sr.No

Name

Relationship

Age/Sex

Education

Occupation

Health

Attitude

Family Genogram

Family History of Mental & Medical illness

Personal History

Pre-natal

Planned/Unplanned Conception

Pregnancy Complications

Maternal Health Issues

Exposure Risks

Nutritional Status

Fetal Movements

Neo natal and natal

Term

Delivery place

Delivery Type

Presentation

Head Injury during birth

Birth Weight

Prolapsed Cord

Birth Cry

Colour of baby

Congenital anomaly

Multiple pregnancies

Complications during birth

Illness

Any others (Specify)

Post- natal

Infections

Jaundice

Feeding problems

Failure to thrive

Injury

Convulsions

Specify if details known

Any others (Specify)

Gross Motor	Expected	Fine Motor/Cognitive	Expected
Neck holding	3 Months	Mature pincer grasp	1 year
Stands alone	9 Months	Scribbles	1 ½ years
Walks alone	15 Months	Copies a circle	3 years
Runs/walks up and down	2 Years	Identifies body part	4 years
Rides a tricycle	3 years	Tells address/knows rules of games	5 years

Language	Achieved at	Social	Expected
Babbling	6 months	Social smile	2 months
Disyllables	9 months	Recognizes mother	3 months
2-3 word sentences	2 years	Stranger anxiety	6 months
Knows full name and gender	3 years	Separation anxiety	1 year
Tells a story/poem	4 years	Pretend/parallel play	2/ 2 ½ years
Asks meaning of words	5 years	Associative/co-operative play	3/ 4 years

Self Help	Expected	Achieved at
Feeds independently	18 months
Brushes teeth	3 years
Bowel Control	< 4 years
Bladder Control	< 5 years
Dresses self	5 years
Others, specify

Home environment:

Physical Environment

Emotional Environment

Patterns of Parental Functioning

Patterns of Family dynamics

(Patient’s relationship with family members, Interpersonal relationship among family members, Decision Making process, Interaction pattern and Family support system)

Reasons for condition of the child as perceived by the family

(include knowledge regarding illness and misconceptions, if any)

Scholastic history:

Type of school

Others

Age of entry

Schooling details (changes in schools, duration with reason)

Scholastic performance

Good
Average
Poor
Not Known (Mention Failure if any)

Mention

Play History:

Play behaviour

Enjoys play
Not interested in play
Observes others while playing
Others

Play preference

Specify

Leisure time activities

Special likes and dislikes

Sexual and marital history:

Attained menarche

Yes
No
Not Applicable

(response birth Course

Details of menstruation

(Duration of usual cycle, regular/irregular, associated with physical or psychological symptoms or not, information and attitude towards mensuration, last menstrual period, duration and reasons of amenorrhea, if any)

Gained sexual knowledge (from whom and when)

Sexual activities

(current and past, include any details of childhood sexual abuse if available)

Marital status

(if married, then mention age at marriage, parental consent, child’s consent and relevant details about spouse, role allocation and sharing of responsibilities between partners, sexual relations and contraception, genogram for family of procreation)

Occupational History

Pre morbid Temperament:

Activity level (how active is your child? Do you find him so active that he runs rather than walks or is so he inactive that he hardly moves? While eating does he eat staying still or does he keep moving about?)

Attention span and persistence (if you try to interrupt your child’s activity, does he try to go back to it or does he forget it? If your child finds a game or a piece of work difficult, does he turn to another activity or keeps on trying until he learns it?)

Approach withdrawal (what is your child’s first reaction when he meets children of his age for the first time? If he is given a new food item or placed in a new situation, what is his first reaction?)

Adaptability (if your child has been shy with some other children, how long does it take him to mix and get friendly? Does he settle back in school routine quickly after a long holiday?)

Distractibility (if he is annoyed or is in bad mood, can he be easily joked out of it or it very to do so? Do you find that when he is engrossed in an interesting task, you have to call out several times before he hears a response)

Intensity of reactions (when he is not given something that he wants, how does he behave? What is his reaction if he is given some food that he likes very much?)

Threshold of responsiveness (does he seem to bother by minor noises or sounds or does he ignore those? Does the child have to be seriously injured before he comments, cries about cuts/bruises?)

Quality of mood (is your child generally happy, satisfied or generally unhappy or discontented? When playing with other children, does he argue/fight with them?)

Rhythmicity (does your child feel hungry/go to sleep/have bowel movement at the approximately same time every day?)

Impression

Slow to warm up
Easy going
Difficult

Behavioural observation

General appearance and Behaviour (physical appearance, appropriate to age, body built and size, dress, physical handicaps in any):

Relationship capacity and sociability (response to separation from parents, reaction to interview situation and relation with interviewer):

Spontaneous motility and activity level (retarded, hyperkinetic, quiet):

Speech (flow, form, level of development of speech, inappropriate use of speech):

Affective Behaviour (any appearance of anxiety, fear, depression, shyness, including child’s attitude towards the examiner):

Attention Span and distractibility (assign some simple task as drawing, writing, also judge from ability to engage in conversation):

Intellectual capacity (ask the child to show body parts, identify common objects by name or uses, name primary colours, draw figure appropriate to age):

Stated interests and content of thought (child’s evaluation of problems, any disturbances of thought):

Motivational insight (child’s knowledge of reasons for problems, desire for help, sense of own capacity for change):

Play behaviour (leave the child with toys in a room with observer, parent can be allowed to be with the child initially):

Mental Status Examination

Language of interview

Time taken

General Appearance (physical appearance, appropriate to age, body built, dress, bodily hygiene, grooming, touch with surroundings, eye contact, facial expressions, posture):

Attitude (cooperative, uncooperative, attentive, evasive, guarded, suspicious, hostile)

Manner of relating (relaxed, tense, overfamiliar, aggressive, disinhibited, withdrawn, others)

Rapport established (easily, with difficulty, not established)

Motor Behaviour (normal, hyperactive, inactive, aggressive, abnormal movements or postures, catatonic features, hallucinatory behaviour, involuntary movements if any)

Speech (intensity, tone, quality, prosody, reaction time, speed, ease of speech, relevance, coherence, goal directedness, productivity, manner, deviation)

Cognitive Functions

Attention and Concentration

Orientation

Memory

Abstract Ability

Calculation

General Information

Affect

Subjective

Objective (quality, appropriateness, range, reactivity, mobility, communicability)

Thought (stream, form, possession, content, include verbatim for content)

Perception and other phenomenon:

Management Plan

Contact Information

Name

Date

Contact information:

My current residential address:

Address Line 1

Address Line 2

City

State

Zip Code

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Child Intake

Personal Information:

Personal History

Pre-natal

Neo natal and natal

Post- natal

Home environment:

Patterns of Parental Functioning

Scholastic history:

Play History:

Sexual and marital history:

Pre morbid Temperament:

Behavioural observation

Mental Status Examination

Cognitive Functions

Affect

Perception and other phenomenon:

Contact Information

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