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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