Child/Adolescent Health Histor...
(List names of any other medications NOW prescribed that were not listed above)
Past Psychiatric History
Past Medical History
(If applicable, indicate if parents are divorced, separated and nature of any custody arrangement or details relating to current foster, guardianship arrangements)
(Also, list any involvement with resource classes, IEP or having been held back a year in school)
(more space provided below if needed to provide additional information)
(Family members of the child means blood relatives such as mother, father, siblings, aunts, uncles, grandparents, cousins)
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