Packet for patients five years of age and older - Atlantic Health System
Packet for patients five years of age and older - Atlantic Health System
Packet for patients five years of age and older - Atlantic Health System
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PEER RELATIONSHIPS<br />
Is your child interested in other children? Yes / No___________________________________<br />
Does your child seek friendships with peers? Yes / No________________________________<br />
Is your child sought out by peers <strong>for</strong> friendship? Yes / No _____________________________<br />
Does your child play with children primarily his or her own <strong>age</strong>? Yes / No ________________<br />
Younger? _________Older? _____________<br />
Describe briefly any problems your child may have with peers<br />
__________________________________________________________________________________<br />
________________________________________________________________________________<br />
Social / Development<br />
What are your child's favorite toys/ activities?_______________________________<br />
______________________________________________________________________<br />
How much TV does your child watch a day?<br />
______________________________________________________________________<br />
What does your child dislike doing most?<br />
______________________________________________________________________<br />
What do you like most about your child?<br />
______________________________________________________________________<br />
Does your child ever help clean up or put away their toys/do chores? Yes/No<br />
_____________________________________________________________________<br />
FAMILY HISTORY:<br />
COMPLETE ALL KNOWN INFORMATION<br />
Mother_________________________ DOB_________________<br />
Currently: Married___Single___Divorced___Widowed___Separated_____<br />
Years married to current spouse: _________________________________________<br />
School: Highest grade completed_________________________________________<br />
Learning problems_____________________________________________<br />
Attention problems_____________________________________________<br />
Behavior/Social problems_________________________________________<br />
Medical problems______________________________________________<br />
Have any <strong>of</strong> mother’s blood relatives experienced medical (especially ventricular arrhythmias),<br />
developmental, neurological, psychiatric or emotional difficulties? If so, briefly describe:<br />
___________________________________________________________________________<br />
___________________________________________________________________________<br />
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