G. F. Still Clinic Developmental Social History Form G. F. Still Clinic Developmental & Social History G. F. Still Clinic Developmental & Social History Email to receive your copy (Optional) Confirm Email to receive your copy (Optional) Enter a confirmation email address. Date * Child's Name * Date of Birth * Gender * M F Parent/Guardian Name * Relationship to Child * How did you hear about the G. F. Still Clinic? What are your concerns? Current Social History Name of School * Grade Level * Favorite activities/hobbies Organized sports participation Medication History Does the patient take prescribed or over the counter medication daily? * Yes No Medication Dose Frequency Medication Dose Frequency Allergies Gestational Risk Factors. Did any of these occur during pregnancy. (Select Only One) Mother took medication * Yes No N/A Mother smoked cigarettes * Yes No N/A Mother drank alcohol * Yes No N/A Mother used illicit drugs * Yes No N/A Premature birth * Yes No N/A If yes, gestational age? Delivery Risk Factors. At the time of birth, did any of these occur? (Select Only One) Fetal distress * Yes No N/A Low birth weight (<5 pounds or 2000 gms) * Yes No N/A Anoxia (lack of oxygen, blue baby) * Yes No N/A Risk Factors. Did your child have any of the following? (Select Only One) Tics * Yes No N/A Treated? * Yes No Hearing problems * Yes No N/A Treated? * Yes No Vision problems * Yes No N/A Treated? * Yes No Lead poisoning * Yes No N/A Treated? * Yes No Head injury * Yes No N/A Treated? * Yes No Neurological issues/deficits * Yes No N/A Treated? * Yes No Cardiac concerns / Heart Disease * Yes No N/A Treated? * Yes No Asthma * Yes No N/A Treated? * Yes No GI / Stomach issues * Yes No N/A Treated? * Yes No Psychiatric History. Has your child ever been diagnosed with the following? (Select Only One) ADHD or ADD * Yes No N/A Oppositional Defiant Disorder * Yes No N/A Conduct disorder * Yes No N/A Tic Disorders (e.g., Tourettes) * Yes No N/A Learning Disability/Disorder * Yes No N/A Language/Communication Disorder * Yes No N/A Eating Disorder (Anorexia/Bulimia) * Yes No N/A Feeding Disorder * Yes No N/A Intellectual Disability * Yes No N/A Autism or Pervasive Developmental Disorder * Yes No N/A Enuresis (Bedwetting) * Yes No N/A Encopresis (Soiling) * Yes No N/A Depression * Yes No N/A Bipolar Disorder * Yes No N/A Separation Anxiety * Yes No N/A Social Phobia * Yes No N/A Generalized Anxiety Disorder * Yes No N/A Post-Traumatic Stress Disorder * Yes No N/A Obessive-Compulsive Disorder * Yes No N/A Panic Disorder * Yes No N/A Has he/she ever seen a professional such as a counselor, psychologist, or psychiatrist for any reason? * Yes No N/A If yes, for what conditions? Are they currently being followed by this professional? * Yes No If yes, please explain the reason for transferring care. If your child has ever had Psycho-educational testing, please elaborate. Medications Has he/she ever taken medication for any ADHD/psychological/psychiatric problem? * Yes No N/A Medication 1 Taking Currently Yes No N/A Prescriber Date Started Date Stopped Condition Treated Total Daily Dose Benefit Side effect Medication 2 Taking Currently Yes No N/A Prescriber Date Started Date Stopped Condition Treated Total Daily Dose Benefit Side effect Medication 3 Taking Currently Yes No N/A Prescriber Date Started Date Stopped Condition Treated Total Daily Dose Benefit Side effect Family Risk Factors. Do any of your relatives have any of the following? I so, who? Depression * Yes No N/A Relative ADHD * Yes No N/A Relative Manic-depression (Bipolar) * Yes No N/A Relative Anxiety * Yes No N/A Relative Alcohol abuse * Yes No N/A Relative Other substance abuse * Yes No N/A Relative Conduct problems/Trouble with Law * Yes No N/A Relative Learning Problems * Yes No N/A Relative Cardiac Issues * Yes No N/A Relative High Blood Pressure * Yes No N/A Relative Asthma * Yes No N/A Relative If you are human, leave this field blank. Submit
