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Patient and Family Questionnaire
Home
Patient and Family Questionnaire
Patient and Family Questionnaire
Patient and Family Questionnaire
UHS-Meridell
2023-10-10T12:40:54-04:00
Step
1
of
7
14%
Patient Legal Name
First
Last
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
1. FAMILY OF ORIGIN AND CURRENT CARETAKERS (check all that apply):
Biological Parents
Mother
Father
Name(s)
Adoptive Parents
Mother
Father
Name(s)
Step-parents
Mother
Father
Name(s)
Deceased Parents
Mother
Father
Name(s)
Paternal grandparents
Mother
Father
Name(s)
Deceased grandparents
Mother
Father
Name(s)
Other
If not biological parent, how, and at what age did patient come into your care:
Non-custodial
Mother
Father
Name(s)
No rights
Mother
Father
Name(s)
Custody of child with (legal guardian)
Name(s)
Custody dispute in progress
Current status
Describe custody arrangements (if applicable)
Will bring court documents at admission
Will fax court documents
Divides time between households
Describe
2. CURRENT HOUSEHOLD MEMBERS LIVING WITH PATIENT (parents, siblings, relatives and friends):
Relationship to Patient
Name
Age
Describe Relationship with Household Member
3. SIGNIFICANT FAMILY MEMBERS / RELATIVES / OTHERS NOT IN SAME HOUSEHOLD:
Relationship to Patient
Name
Age
Describe Relationship with Household Member
4. FAMILY HISTORY OF MENTAL HEALTH ISSUES:
Bio Maternal History Unknown Mother’s Side Relationship to Patient
Psychiatric
Neurological
History of Suicide
Substance Abuse
Learning Disabilities
Aggression
Legal Issues
Other
Bio Paternal History Unknown Father’s Side Relationship to Patient
Psychiatric
Neurological
History of Suicide
Substance Abuse
Learning Disabilities
Aggression
Legal Issues
Other
5. SOCIAL HISTORY:
Patient is able to create friendships
Never
Rarely
Sometimes
Always
Patient is able to maintain friendships.
Never
Rarely
Sometimes
Always
Patient is able to relate to peers in a respectful manner
Never
Rarely
Sometimes
Always
Patient is able to relate to adults in a respectful manner
Never
Rarely
Sometimes
Always
6. DEVELOPMENTAL HISTORY:
Prenatal:
Normal or unremarkable
No information available
Problems with (eg, complications during pregnancy/delivery, substance use, etc.)
Developmental Milestones:
Normal Limits
Delayed
No information available
Walking:
Early
12-months
Later
Talking in 3-word sentences:
Early
24-months
Later
Toilet Training:
Early
36-months
Later
Handedness:
Right
Left
Birth to 1-year:
Normal or unremarkable
No information available
Problems with:
2 to 5 years:
Normal or unremarkable
No information available
Problems with:
7. EDUCATION:
Current Grade Level
History of repeating a grade:
Yes
No
Which grade(s):
Current grades:
Improving
Declining
Learning barriers:
Reading & writing difficulties
Speech impediments
Impaired vision
Fatigue
Other, description of symptoms and age when began:
Patient is currently enrolled in school
School name:
Address:
Patient is currently home schooled.
Reason:
Not enrolled or attending school due to:
Dropped out
Refuses to attend
Other
School behavioral problems?
Yes
No
Details (eg, age of onset, specific behaviors, school consequences):
Patient has a history of requiring 1:1 educational aide for behavioral management?
Yes
No
Patient has a 504 plan for:
Medical
Behavioral
Other
Special Educational Services:
Yes
No
What is their qualifying diagnosis?
Date of last IEP meeting:
8. ELOPEMENT:
NO HISTORY OF RUNNING AWAY
Threatens to run away?
No
Yes
Interventions have prevented elopement?
No
Yes
Patient has run away from home?
No
Yes
When did patient last run?
If yes, frequency:
Is it planned?
How long was patient gone?
Where does patient go?
9. HISTORY OF SELF HARM IDEATIONS / ATTEMPTS:
No History of Self Harm
History of self-harming behaviors?
Yes
No
Describe:
Banging head
Scratching
Biting
Hitting
Pulling out or shaving hair, eyelashes or eyebrows
Cutting
Burning
Self-Piercing
Self-tattooing
Other:
Patient’s mood during suicidal ideations?
Angry
Sad
Depressed
Manipulative
Other:
Patient has verbalized suicidal ideations?
Yes
No
When:
Patient has verbalized plan?
Yes
No
Describe:
Patient has made a suicidal gesture/attempt?
Yes
No
Details:
Suicidal gesture / attempts made could / would have resulted in patient’s death without interventions?
Yes
No
Date
Age
Method
Injury
Treatment / Outcome
Patient has access to a gun or other weapons?
Yes
No
There are guns or other weapons in the home?
Yes
No
Describe how they are secured:
If weapons and/or other potentially dangerous items in the home are not secured, how will this be managed in the future?
Patient has access to lethal means other than home environment?
Yes
No
Describe:
10. HISTORY OF VIOLENT / AGGRESSIVE / ANTISOCIAL BEHAVIORS:
Patient has a history of violent or aggressive behaviors
Yes
No
Aggressive behaviors have been directed towards:
Parents
Siblings
Peers
School
Aggressive behaviors are escalating and/or are more frequent
Yes
No
Patient plans aggressive acts
Yes
No
Patient is very careful to protect self when aggressive
Yes
No
Patient can control behavior when aggressive
Yes
No
Patient hides or attempts to hide aggressive acts
Yes
No
Patient steals from:
Family
Friends
School
Stores
Neighbors
Other:
Patient has history of delusions or command hallucinations prompting them to be aggressive
Yes
No
Patient experiences rapid mood swings
Yes
No
Patient experiences paranoid ideation
Yes
No
Physical aggression appears to be without gain or purpose
Yes
No
Patient aggression is unplanned, out of the blue
Yes
No
Patient is completely out of control when aggressive
Yes
No
Patient exposes self to physical harm when aggressive
Yes
No
Patient destroys own property without apparent profit or gain
Yes
No
Patient vandalizes or destroys others property or belongings?
Yes
No
Patient has been physically aggressive with a weapon?
Yes
No
Describe (eg, patient age, victim, weapon used, extent of injury to victim):
Patient has been physically aggressive and/or cruel to animals?
Yes
No
Describe:
Patient has expressed a plan to retaliate against someone?
Yes
No
Who?
What are the precipitating events that typically trigger the patient’s aggressive behaviors?
Types of physical aggression towards others:
Pushing
Punching
Head Butting
Stabbing
Shoving
Biting
Pushing Down
Choking
Hitting
Scratching
Kicking
Smothering
11. LEGAL HISTORY:
No Legal Issues
Patient has been arrested?
Yes
No
Describe (eg, patient age, offense, outcome):
Patient is currently on probation?
Yes
No
Name and county of Probation Officer:
Patient has charges pending?
Yes
No
Describe (eg, patient age, offense, court date):
12. PATIENT HISTORY OF ALCOHOL AND DRUG USE:
No History of Use
Suspected, unconfirmed
Experimentation
Becoming problematic
Big problem
Generally uses
Alone
With others
How does the patient procure or pay for drugs?
Check all used:
Pain Medications
Tranquilizers
Barbiturates
Marijuana
Inhalants
Methadone
Crystal Meth
Misuse of over the counter or prescription medications
Tobacco
Alcohol
Stimulants
Hallucinogens
Cocaine / Crack
Opiates
Ecstasy / GHB
PCP
Substance Checked or Other
Type
Age of First Use
Date of Last Use
Age Regular Use Began
Current Use Pattern
Highest Quantity in 24 hours
Diagnosis of Chemical Dependency / Abuse?
Yes
No
Drug of Choice?
Treatment previously received for drug use?
Therapy / Counseling
Hospitalization / Rehab
Has used again since treatment?
Yes
No
How soon after treatment?
13. SEXUAL:
Has identified sexual preference as:
Heterosexual
Bi-Sexual
Gay / Lesbian
Other
Identifies as Transgender?
Yes
No
Transgender Male / Trans man / FTM
Transgender Female / Trans woman MTF
What is the patient’s legal name?
(Optional) What is patient’s preferred name or nickname?
(Optional) What pronouns does patient use to refer to self (eg, he/him, she/her)?
What is the gender designation on patient’s medical insurance records?
Male
Female
Patient is sexually active?
Yes
No
Unsure
Patient practices safe sex?
Yes
No
Unsure
Sexual behaviors were with / toward: (Please check all that apply)
Same age peers
Younger
Older
Parents
Siblings
Opposite sex
Same sex
Both male and female
Animals
Sexual Behaviors (Please Check All That Apply)
Sexual preoccupation
Sexually explicit talk
Sexually explicit writings / drawings
Has used electronic media for “sexting” / sex chat rooms / viewing pornography / posting inappropriate pictures of self
Engaged in voyeurism / peeping
Exposed self to others
Sexually promiscuous
Masturbation in presence of others
Acted out sexually in a treatment setting
Touched others sexually without their permission
Sexually aggressive / predatorial
Gender identify issues
Has experienced a sexual assault or been victimized?
Yes
No
Age / perpetrator / circumstances:
Was this suspected abuse of patient reported to a State protective service?
Yes
No
Please provide additional information on checked behaviors above:
Received serious consequences due to sexual behaviors (eg, school expulsion/suspension, legal/social services involvement)?
Yes
No
What age was patient? What were charges?
Patient accepts responsibility for their sexual behavior?
Yes
No
Patient is able to manage sex urges?
No
Rarely
Mostly
Yes
Has patient received treatment for sexual behaviors?
Yes
No
Describe:
Does patient have pet allergies?
Yes
No
Does patient have history of aggression to animals?
Yes
No
Does patient have anxiety or history of being attacked by an animal?
Yes
No
For any responses “yes” to above questions, please specify below including type of animal and description of incident(s):
14. BEREAVEMENT:
Name of Person / Other
Relationship to Patient
Type of Loss (Death, Divorce, Etc.)
Age of Patient at Time of Loss
How Has This Loss Affected the Patient?
15. CULTURAL INFLUENCES / RELIGIOUS BACKGROUND / CURRENT ACTIVITY:
Patient has expressed a belief system or spiritualness?
Yes
No
Patient has a religious affiliation:
Yes
No
Patient attends religious services? Name of church / temple?
Yes
No
Patient’s affiliation with a place of worship is part of his/her support system?
Yes
No
Explain:
Patient and family’s cultural / ethnic background?
The family has specific cultural/ethnic/religions factors that should be considered during treatment?
Yes
No
Explain:
16. DIAGNOSTIC HISTORY:
The patient has previously been diagnosed with:
Adjustment Disorder
Anxiety Disorder
ADD / ADHD
Autism Spectrum Disorder
Bipolar Disorder
Cerebral Dysrhythmia
Conduct Disorder
Disruptive Mood Dysregulation
Eating Disorder
Fetal Alcohol Syndrome
Impulse Control Disorder
Intermittent Explosive Disorder
Learning Disorder
Major Depressive Disorder
Mood Disorder
Neurodevelopmental Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Paranoid Disorder
Personality Disorder
Pervasive Development Disorder
Post-Traumatic Stress Disorder
Psychosis
Reactive Attachment Disorder
Schizoaffective Disorder
Substance Abuse
Other
Other
17. HISTORY OF PREVIOUS TREATMENT:
Last treatment more than 2 years ago
Inpatient hospitalization (Acute), Residential Treatment Center (RTC), Intensive Outpatient (IOP), Partial Hospitalization (PHP), over the last few years.
Name of Facility (Most Recent First)
Dates of Treatment
MM slash DD slash YYYY
Sending Record to Meridell
(Yes/No):
Treatment Results
(Positive/Negative/None):
Patient placed in a private bedroom due to patient behaviors (eg, aggression, sexual acting out)?
Yes
No
Specify reason:
Did patient require special staffing (eg, 1:1)?
Yes
No
Specify:
Did patient require seclusions, physical holds or injections due to behavioral issues?
Yes
No
Describe:
18. RESIDENCE / CONTACT INFO:
Patient’s Primary Residence With:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone Number
Cell Phone Number
Other Phone Number
Patient’s Secondary Residence With:
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone Number
Cell Phone Number
Other Phone Number
19. PRECIPITATING EVENTS NECESSITATING TREATMENT INTERVENTIONS AT THIS TIME:
Completed by:
First
Last
Relationship to Patient:
Email Address:
Date
MM slash DD slash YYYY
Details (eg, accommodations, age when services began, services received):
*Please provide most recent copies of educational plans at the time of admission.
Email
This field is for validation purposes and should be left unchanged.
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