Illini Pediatrics LLC, DBA Ideal Pediatrics

Behavioral Intake for Older Kids (Age 8 and older)

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

School /Education

Name of School Best contact person at school Their Ph. # Current grade: Has child ever had to repeat a grade? Performance since onset: Home Schooling Requires a special education setting or tutoring at school for major subjects because of symptoms

Vanderbilt Assessment

Each rating should be considered in the context of what is appropriate for the age of your child. When completing this section, please think about your child's behaviors in the past 6 months.

Is this evaluation based on a time when the child 1. Does not pay attention to details or makes careless mistakes with, for example, homework * 2. Has difficulty keeping attention to what needs to be done 3. Does not seem to listen when spoken directly to 4. Does not follow through when givien directions and fails to finish activities (not due to failure to understand) 5. Has difficulty organizing tasks and activites * 6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effot 7. Loses things necessary for tasks or activites (toys, assignments, pencils etc) 8. Is easily distracted by noises o other stimuli. 9. Is forgetful in daily activites 10. Fidgets with hands or feet or squirms in seat 11. Leaves seat when remaining seated is expected 12. Runs about or climbs too much when remaining seated is expected 13. Has difficulty playing or beginning quiet playing activities 14. Is 'on the go' or often acts as if 'driven by a motor' 15. Talks too much 16. Blurts out answers before questions have been completed 17. Has difficulty waiting his or her turn 18. Interrupts or intrudes in on others' conversations and/or activities 19. Argues with adults 20. Loses temper 21. Actively defies or refuses to go along with adults' requests or rules 22. Deliberately annoys people 23. Blames others for his or her mistakes or misbehaviors 24. Is touchy or easily annoyed by others 25. Is angry or resentful 26. Is spiteful and wants to get even 27. Bullies, threatens, or intimidates others 28. Starts physical fights 29. Lies to get out of trouble or to avoid obligations (ie, "cons" others) 30. Is truant from school (skips school) without permission 31. Is physically cruel to people 32. Has stolen things that have value 33. Deliberately destroys others' property 34. Has used a weapon that can cause serious harm (bat, knife, brick, gun) 35. Is physically cruel to animals 36. Has deliberately set fires to cause damage 37. Has broken into someone else's home, business, or car 38. Has stayed out at night without permission 39. Has run away from home overnight 40. Has forced someone into sexual activity 41. Is fearful, anxious, or worried 42. Is afraid to try new things for fear of making mistakes 43. Feels worthless or inferior 44. Blames self for problems, feels guilty 45. Feels lonely, unwanted, or unloved; complains that "no one loves him or her" 46. Is sad, unahppy, or depressed 47. Is self-conscious or easily embarrassed

PERFORMANCE

48. Overall school performance 49. Reading 50. Writing 51. Mathematics 52. Relationship with parents 53. Relationship with siblings 54. Relationship with peers 55. Participation in organized activities (eg, teams) Grading area for provider

SCREEN FOR CHILD ANXIETY RELATED DISORDER (SCARED)

Please try to have child complete this section

1. When I feel frightened, it is hard to breathe 2. I get headaches when I am at school 3. I don't like to be with people I don't know well 4. I get scared if I sleep away from home 5. I worry about other people like me 6. When I get frightened, I feel like passing out 7. I am nervous 8. I follow my mother or father wherever they go 9. People tell me that I look nervous 10. I feel nervous with people I don't know well 11. I get stomachaches at school 12. When I get frightened, I feel like I am going crazy 13. I worry about sleeping alone 14. I worry about being as good as other kids 15. When I get frightened, I feel like things are not real 16. I have nightmares about something bad happening to my parents 17. I worry about going to school 18. When I get frightened, my heart beats fast 19. I get shaky 20. I have nightmares about something bad happening to me 21. I worry about things working out for me 22. When I get frightened, I sweat a lot 23. I am a worrier 24. I get really frightened for no reason at all 25. I am afraid to be alone in the house 26. It is hard for me to talk with people I don't know well 27. When I get frightened, I feel like I'm choking 28. People tell me that I worry too much 29. I don't like to be away from my family 30. I am afraid of having anxiety (or panic) attacks 31. I worry that something bad might happen to my parents 32. I feel shy with people I don't know well 33. I worry about what is going to happen in the future 34. When I get frightened, I feel like throwing up 35. I worry about how well I do things 36. I am scared to go to school 37. I worry about things that have already happenedield216 38. When I get frightened, I feel dizzy 39. I feel nervous when I am with other children or adults and I have to do something while they watch me (for example: read aloud, speak, play a game, play a sport) 40. I feel nervous when I am going to parties, dances, or any place where there will be people that I don't know well 41. I am shy Leave blank for provider to grade.

PHQ9

1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself--or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed. Or the opposite--being so fidgety or restless that you have been moving around a lot more than usual 9. Thought that you would be better off dead, or of hurting yourself 10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Please leave blank for provider notes

You are not completed with the behavior intake. Please allow 2-3 days for the provider to review these forms. Our office will contact you at the time to discuss setting up an appointment. (Sorry for the length of this form)