Medical Status & Treatment History Current Medications (not listed above): Dosage & Date/Time Last Taken: Is the medication helpful or problematic: . Medication Allergies: Currently Under Physician Care For: Physician’s Name: Conditions Treated In The Past: Provider/Dates: Medical Hospitalization History: Physical Disabilities: Current Communicable Diseases: A B C ☐HIV/AIDS ☐Hepatitis ☐Hepatitis ☐Hepatitis ☐TB(Tuberculosis) Lice Lice ☐MRSA ☐Influenza ☐Head ☐Scabies ☐Body ☐STIs ☐Other Currently Pregnant: Yes No ☐ ☐ Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Developmental Disability Pregnancy/Delivery Complications: Yes No ☐ ☐ Describe: Met Developmental Milestones On Time: If no, describe: Walked Talked Crawled Toilet Trained Feeding ☐ ☐ ☐ ☐ ☐ History of Special Education Ruling: Yes No ☐ ☐ If yes, describe: Documented IQ below 70: Yes No ☐ ☐ If yes, describe: Documented sub-average intellectual functioning before age 18: ☐ If yes, describe: Yes No ☐ Documented Adaptive Functioning Deficits: Yes No ☐ ☐ If yes, describe: Specific Observed Adaptive Functioning Deficits: Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other President: Oriented to Date: Time: Place: Mental State Exam *Cue for three words (provide words) Counting Response: Word Recall: Completed Written Command: Yes No If no, describe: ☐ ☐ What do you understand the reason for our meeting today to be? Source of Information: Review ☐Respondent ☐Affiant ☐Chart ☐Other Psychiatric Symptoms Past Month Respondent( R ) Informant(I) Mood Symptoms R I Mood Symptoms R I Behavioral Symptoms R I ☐ Depressed mood/Appears Sad ☐ ☐ ☐ ☐ Dizzy to Others ☐ ☐ “ ☐ ☐Attempts ☐ Enjoys Very Little ☐ ☐ ☐ ☐ Shaking/Trembling ☐ ☐ Defies Requests ☐ ☐ ☐ Cries Frequently ☐ ☐ ☐ ☐ Sweating Angry & Resentful ☐ ☐ ☐Excessive ☐ ☐ Decrease in Appetite ☐ ☐ ☐ ☐ Shortness of Breath Sullen ☐ ☐ ☐ ☐ ☐ Increase in Appetite ☐ ☐ ☐ ☐ Tingling in Hands or Feet Irritable ☐ ☐ ☐ ☐
Medical Status & Treatment History Current Medications (not listed above): Dosage & Date/Time Last Taken: Is the medication helpful or problematic: . Medication Allergies: Currently Under Physician Care For: Physician’s Name: Conditions Treated In The Past: Provider/Dates: Medical Hospitalization History: Physical Disabilities: Current Communicable Diseases: ☐HIV/AIDS ☐Hepatitis A ☐Hepatitis B ☐Hepatitis C ☐TB(Tuberculosis) ☐MRSA ☐Influenza ☐Head Lice ☐Scabies ☐Body Lice ☐STIs ☐Other Currently Pregnant: ☐ Yes ☐ No Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Developmental Disability Pregnancy/Delivery Complications: ☐ Yes ☐ No Describe: Met Developmental Milestones On Time: Walked ☐ Talked ☐ Crawled ☐ Toilet Trained ☐ Feeding ☐ If no, describe: History of Special Education Ruling: ☐ Yes ☐ No If yes, describe: Documented IQ below 70: ☐ Yes ☐ No If yes, describe: Documented sub-average intellectual functioning before age 18: ☐ Yes ☐ No If yes, describe: Documented Adaptive Functioning Deficits: ☐ Yes ☐ No If yes, describe: Specific Observed Adaptive Functioning Deficits: Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Oriented to Date: Time: Place: *Cue for three words (provide words) President: Mental State Exam Counting Response: Word Recall: Completed Written Command: ☐ Yes ☐ No If no, describe: What do you understand the reason for our meeting today to be? Source of Information: ☐Respondent ☐Affiant ☐Chart Review ☐Other Psychiatric Symptoms Past Month Respondent( R ) Informant(I) Mood Symptoms R I Mood Symptoms R I Behavioral Symptoms R I ☐ Depressed mood/Appears Sad ☐ ☐ ☐ Dizzy ☐ ☐ ☐Attempts to “ Others ☐ ☐ ☐ Enjoys Very Little ☐ ☐ ☐ Shaking/Trembling ☐ ☐ ☐ Defies Requests ☐ ☐ ☐ Cries Frequently ☐ ☐ ☐Excessive Sweating ☐ ☐ ☐ Angry & Resentful ☐ ☐ ☐ Decrease in Appetite ☐ ☐ ☐ Shortness of Breath ☐ ☐ ☐ Sullen ☐ ☐ ☐ Increase in Appetite ☐ ☐ ☐ Tingling in Hands or Feet ☐ ☐ ☐ Irritable ☐ ☐
revised-2016-Youth-Pre-Evaluation-Screening-form.docx