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Form- Child History
Form- Child History
Child History Form
Please give as many details as you can
Child's date of birth and age
School attended and current year
Biological mother's profession
Biological father's profession
Number of full / half siblings and position in family
Address Line 2
County / State / Region
ZIP / Postal Code
Informant's relationship to the child
Please tell us what you are particularly concerned about, with as much detail as possible. How long has this been a problem?
Was the child born by full term normal delivery? Any problems after birth?
Please tell us about any early risk factors in the child's history
Low birth weight
Early trauma (ie physical sexual or emotional abuse)
Head injury involving loss of consciousness
Parental mental health issues
Please give us any more information you may have about this
Any delay in starting sitting up / walking / talking (early milestones)
Was the child active as a baby and young child? Any other early characteristics?
Tick behaviours which applied in primary school - please check all that apply
Struggled to listen/zoned out
Naughty / in trouble with teachers
Difficulty with reading
Difficulty with writing
Difficulty with numbers/maths
Problems with friendships
Did not achieve potential
Primary school experience - any comments re above issues?
Academic level at end of primary school (aged 11)
Describe secondary school experience up to GCSE. How was it similar or different from primary school?
How many GCSEs did the child get with approximate grades?
Describe sixth form school or college experience. What exams did the child get with grades if remembered. Did you achieve your potential?
Any medical diagnoses? Any medication?
Does the child receive extra support at school? Please give details
Has the child ever been excluded from school? Please give details
Peer relationships – describe quality of the child's friendships both in and out of school with any concerns
Has the child seen psychiatrists before for mental health? Please give details
Has the child struggled much with low mood? Ever taken antidepressants or other mental health medications?
What about anxiety? What makes the child anxious? Ever had a panic attack?
Briefly summarise any therapy/ counselling the child has had and when. Did it help at all and if so, how?
Has the child ever been in trouble with the law?
Please describe any eating disorders or problems past or present
Does the child have any issues with alcohol or drugs past or present. How much alcohol/ drugs do they use currently, and how often?
Is the child sensitive to eg light, noise, smell, touch etc.?
Was the child slower/ worse than others with learning to tie shoelaces, ride a bike etc.? Any clumsiness?
Any family members with suspected or diagnosed relevant issues?
I agree that ADHD Consultancy may retain and use my personal information for the purpose of completing your report. We may also use your data in anonymised form in research assessing the benefits of our ADHD treatments but this will not affect your confidentiality.
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