Medication: Dosage: How often: Medication: Dosage: How often: Medication: Dosage: How often: Reason: Medication: Dosage: How often: Current medications, dosage, Reason: and reason: Medication: Dosage: How often: Reason: Medication: Dosage: How often: Reason: Impulsivity or hyperactivity Inappropriate/deficient social skills Temper tantrums Abdominal pains/vomiting Anxiety/worry Headaches Clumsiness Has the child ever had a Sleep difficulties problem with: Self-injurious behavior Eating difficulties Forgetfulness Aggression Noncompliance at school Noncompliance at home Suicidal feelings or actions Depressed or sullen mood Social History Update Restless Self-conscious Impulsive Check the following behaviors that describe the child: Feels inferior Concerned with bodily changes Short attention span Overexcited easily Fails to finish tasks Sulks and pouts Argues, quarrels Rapid mood swings Unusual fears Overactive Daydreams Listless Lacks self-confidence Changeable Brags, boasts Bullying others Distractible Being bullied Check factors affecting family: Blended family problems Parent-child conflict Unemployed Sibling conflict Divorce/separation Custody problems Frequent moves Parent conflict Incarcerations
Medication: Dosage: How often: Medication: Dosage: How often: Current medications, dosage, and reason: Medication: Dosage: How often: Reason: Medication: Dosage: How often: Reason: Medication: Dosage: How often: Reason: Medication: Dosage: How often: Reason: Has the child ever had a problem with: Inappropriate/deficient social skills Abdominal pains/vomiting Headaches Sleep difficulties Eating difficulties Aggression Noncompliance at home Depressed or sullen mood Impulsivity or hyperactivity Temper tantrums Anxiety/worry Clumsiness Self-injurious behavior Forgetfulness Noncompliance at school Suicidal feelings or actions Social History Update Check the following behaviors that describe the child: Self-conscious Feels inferior Short attention span Fails to finish tasks Argues, quarrels Unusual fears Daydreams Lacks self-confidence Brags, boasts Distractible Restless Impulsive Concerned with bodily changes Overexcited easily Sulks and pouts Rapid mood swings Overactive Listless Changeable Bullying others Being bullied Check factors affecting family: Blended family problems Unemployed Divorce/separation Frequent moves Incarcerations Parent-child conflict Sibling conflict Custody problems Parent conflict
6.6_social_developmental_history_form.docx