Child Psychiatric Sheet

 

CHI L D PS PSYCHI ATRIC SH SH EET

 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: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… ……………………………………………………………………………………………………………   ……………………………………………………………………………………………………………  |Page1

 

 

…………………………………………………………………………………………………………… ……………………………………………………………………………………………………………   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:   - Complications: 5- Labour: - Pre / post term:

- Post partum depression/ psychosis: 6- Birth weight: |Page3

 

 

7- Post partum complication: - To mother: - To child: 8- Type of feeding: a) Breast feeding:  For  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:

……...……………...……………………………………………………………………………...………  ……………...…..……...………………………………………………………………………………….  …………………..…………...……………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..……………………...…………………………………………………………………  ……...……………...……………………………………………………………………………...………  ……………...…..……...………………………………………………………………………………….  …………………..…………...……………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..……………………...…………………………………………………………………  ……………...…..……...………………………………………………………………………………….  …………………..…………...……………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..……………………...…………………………………………………………………  ……………...…..……...………………………………………………………………………………….  …………………..…………...……………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..……………………...…………………………………………………………………  ……………...…..……...………………………………………………………………………………….  …………………..…………...……………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..……………………...…………………………………………………………………  …………………..…………...……………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..……………………...…………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..……………………...…………………………………………………………………  …………………..………………...………………………………………………………………………  …………………..……………………...…………………………………………………………………  |Page7

 

 

 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: ……………………...……….…………………………………………………………………  …………………………...…….………………………………………………………………  |Page8

 

 

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.

……………………...……….…………………………………………………………………  …………………………...…….………………………………………………………………  |Page9

 

 

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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