CHILD PSYCHIATRIC SHEET
STATE OF AFFAIRES:
- Name:
- Nick name:
- Sex:
- Birth order:
- Age:
- Date of birth:
- Education:
- Occupation:
- Address:
- IQ:
- Handedness:
SOURCE & CAUSE OF REFERRAL:
- Source:
- Cause:
- Date:
COMPLAINT:
- From the patient:
- From the mother:
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FAMILY HISTORY:
A) Psychiatric:
B) Neurological:
C) Others:
Family
settings & Home atmosphere:
A) Father:
- Name:
- Age:
- Education:
- Occupation:
- Special traits: ...
...
...
- Relation with the patient: ...
...
...
B) Mother:
- Name:
- Age:
- Education:
- Occupation:
- Special traits: ...
...
...
- Relation with the patient: ...
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...
...
C) Relation in between:
- Consanguinity:
- Marriage:
- Domineering partner:
- Relation:
- Child is more attached to:
D) Siblings:
- Number & order:
...
...
- Relation in between:
- Jealousy:
- Identification with older sibling:
E) Other care takers:
F) Home atmosphere:
- House:
- Facilities:
- Appliances:
- Size & type of the family:
- Monthly income:
- By whom / other sources:
PERSONAL HISTORY:
A) Pre & Perinatal history:
1- Age of mother at pregnancy:
2- Wanted / unwanted:
3- Desired sex:
4- Pregnancy:
- Complications:
5- Labour:
- Pre / post term:
- Post partum depression/ psychosis:
6- Birth weight:
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7- Post partum complication:
- To mother:
- To child:
8- Type of feeding:
a) Breast feeding:
For how long:
Weaning:
- Sudden/gradual:
- Reaction of the baby:
b) Bottle feeding:
By whom:
B) Infancy & early childhood:
1- Development:
a) Developmental milestones:
Head support :
Sitting alone
:
Standing
:
Walking
:
Running
:
Teething
:
Talking
:
b) Social & Emotional development:
Smile:
Knows his mother:
Neglect/abuse:
c) Toilet training:
Age of the child:
- Start:
- Finish:
By whom:
Reaction of child:
2- Neurotic traits:
...
...
3- Fear:
...
...
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PAST HISTORY:
A) Medical:
- Illness: .....
...
- Treatment (hospitalization):...
...
- Operation: .
...
- Vaccines:
...
B) Psychiatric:
......
......
..
C) Trauma:
......
..
SOCIAL & LEARNING COMPETENCE:
Traits:
( Timid / Shy / Aggressive / Active / Sociable / Defiant / obedient )
......
......
..
......
..
Hobbies:
......
......
..
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School:
- Educational achievements: .....
- Learning abilities: ......
- Regularity: ....
- Relation to peers: ...
Position in group:
Leader/Follower: .....
Active/Passive: .....
- Relations to teachers: ....
- Activity:
Solitary / group: ...
Achiever: ....
- Play:
......
......
..
..
..
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HISTORY OF PRESENT ILLNESS:
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PRESENT MENTAL STATE:
1- General appearance:
- Weight:
- Height:
- Head circumference:
- Prevailing facial expression:
- Cleanliness:
- Dressing:
- Bruising:
- Mannerism:
- Cooperative:
- Behavior:
- Posture:
- Motor activity:
a) General level:
b) Coordination:
c) Compulsive phenomenon:
d) Involuntary movement:
e) Regressive behavior:
2- Parent-Child interaction:
- In waiting room:
- During the interview:
........
....
3- Effect of separation & reunion:
- Distress
- Lack of affect:
....
....
4- Speech & language:
- Appropriate for age:
- Disparity between expressive & receptive language:
- Rate & rhythm:
- Spontaneity:
- In response to questions:
- Latency:
....
....
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5- Conscious: ................................................................................
6- Orientation: .............................................................................
7- Attention: ..................................................................................
- Passive:
- Active: - Days of week:
- Drawing:
- Attention span:
- Persistence:
- Distractibility:
8- Memory: .....................................................................................
- Immediate:
- DF:5
- DB: 3
- Objects:
- Recent:
- 3 objects after 5 min in school age.
- Remote:
9- Mood: ...........................................................................................
- Sad expression, lack of appropriate smiling, tearfulness.
- Anxiety, anger, euphoria.
- Persistent themes in play & fantasy.
Affect:
- range of emotional expressivity:
- appropriate to thought content:
- ability to move smoothly from one affect to another:
10- Social interaction with interviewer:
- Eye contact: ..............................................................................
- Familiarity/withdrawal: .......................................................
11- Quality of play:
....
....
12- Intelligence clinically: ....................................................
13- Perceptual disorder:
N.B: Transient visual & auditory hallucinations in very young children don't necessarily
represent psychotic illness.
....
....
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14- Thought disorder:
- Formal: ......................................................................................
- Content:
Delusions:
Fear (darkness/animals):
Wishes & fantasies:
Aggressive thoughts & homicidal ideation:
Stubbornness:
Obsessive thoughts:
Suicidal ideation:
15- Judgment:
- Open tape: ................................................................................
- Broke a glass: ..........................................................................
- Broke a pen of your friend: ...............................................
16- Level of general information:
- Seasons, months, feasts, time, fruits, cartoon.
17- Ideas about the interview:
- Why are you coming here?
....
....
....
....
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