Child/Adolescent History Form – Testing – Hollywood Psychology Center

Instructions: Please fill out this form as fully and openly as possible. All private information is held in strictest confidence within legal limits. If certain questions do not apply, leave them blank.

Child Testing

Personal History

Child’s Name

Age

Gender

Weight

Height

Hair Color

Race

Address

City

State/Province

Zip/Postal

Today’s Date

Date of Birth

Home Phone

Years of Education

Has the child been involved in previous testings?

yes

If yes, please describe

Why are you requesting testing?

How long has this problem (from previous question) persisted?

Under what conditions do the problems usually get worse?

Under what conditions are the problems usually improved?

Medical History

Physician’s Name

Physician’s Address

Physician's Address

City

State/Province

Zip/Postal

Most Recent Physical Exam Date

Result of most recent physical exam

List any major illnesses and/or operations

List any major physical concerns occurring at present (e.g. high blood pressure, headaches, dizziness, etc.)

List any physical concerns (e.g. head trauma, seizures, etc) experienced in the past

On average how many hours of sleep does your child receive daily?

Does your child have trouble falling asleep at night?

yes

If Yes, how long has this been a problem?

Describe your child’s appetite (during the past week):

poor appetite

average appetite

large appetite

What medications (and dosages) are being taken at present, and for what purpose?

Hollywood Psychology Center

Child/Adolescent History Form – Testing

Personal History

Medical History

Family History

Developmental History

Educational History

Behaviors of Concern