Illini Pediatrics LLC, DBA Ideal Pediatrics

Behavioral Intake for Younger Kids

Child's Name * Child's Date of Birth * Parent/ Guardian completing this form Contact Ph. Number Previous Primary Physician Other Consultants/ Specialists Symptoms/ Complaints/ Concerns

Family Unit

Who lives in home? Describe family dynamics/ support system: Is there a second home? If so who lives there?

Perinatal History

Gestational age Birth weight Birth length Problems with pregnancy? Describe Problems with delivery? Describe Problems at birth? Describe

Infancy History

Problems in the first year of life? Describe Was child breast fed? If so, how long? Was child colicy? Any other infancy problems?

Allergy History

Is there food intolerance before onset of symptoms? If so, list the food and reaction. Is there an intolerance/allergy to a medication? List medication and reaction. Is there a nasal allergy/ hayfever/ allergic rhinitis? If known, what is child allergic to? Does child of Asthma requiring medicine every day? Does child have any other allergies? Please list what to and the reaction the occurs. Allergy to: Since behavioral symptom onset, have allergy symptoms: List all current medications, dose, date started & prescribing physician List all previous medications, dose, date started & prescribing physician About how many lifetime courses of antibiotics we given before symptom onset?

Immunization Reactions

Any history of immunization reactions? If yes, please list the date, the type of vaccine and the reaction.

Infections and Triggering Factors

Before onset, did child have more infections than siblings or peers? Since onset, has child had more infections that siblings or peers? Do symptoms often worsen a day or more after infcations? Are symptoms usually worse during infections? Do symptoms often worsen 1-3 days before infections? Does stress increase symptoms? Do symptoms increase without an apparent cause?

Course

Months or years before onset, were there any similar, but milder past symptoms? If yes, please describe:

Onset and first month

Date of onset of symptoms Age at onset: Was onset: If rapid, estimate time from first onset to worst symptoms Is there a strep-associated onset? Is there a stress-associated onset?

Description of Course

Course Pattern Overall Course

Family History

Please select if any primary, secondary, or more distant relative has ever had a diagnosis any of the following.

Primary= Parent or sibling

Secondary = Grandparent, Aunt/Uncle or half-sibling

More distant= Cousin, great grandparent, etc.

Symptoms similar to patient ADHD Obsessions/ Compulsions Hoarding Anxiety requiring treament Separation anxiety Tics/Touerette's Other movement disorder Rages/Anger issues Excessive alcohol use Manic/ Depressive/ Bipolar Autism/ Schizophrenia Other personality disorders Chronic Fatigue Fainting, POTS Fibromyalgia Anorexia Nervosa Other eating disorder Any autoimmune illness Thyroid Disorder Arthritis Rheumatic Fever Heart Murmur Spondyloarthritis / back/ lower back pain Lupus Dermatomyositis Sjogren's Sceleroderma Multiple Sclerosis Myesthenia Gravis ITP Gullian-Barre Syndrome Celiac/ Gluten intolerance Type 1 Diabetes Ulcerative Colitis Regional enteritis, crohn's disease Addison's Disease Unusual Hair Loss (alopecia) Psoriasis Exzema Staph/ Skin Infections Immune Deficiency Disorder IV gamma globulin treaments Migraine Headaces

Please press submit to send this entire form to Ideal Pediatrics. Please allow 2-3 days for Dr. Cangas to review. we will contact you to discuss scheduling at that time. Thank you.

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