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 New Patient History
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Please fill out this form prior to your appoinment, print a copy for yourself, and bring it with you to your appointment. Not all fields are required, but please provide as much information as possible.
Online forms are provided as a convenience for patients who choose to use them, but these forms are not secure. Secure forms are currently in development. If you do not feel comfortable entering your information online, you can print a paper copy of the form and either fax it to our office at
914-633-5406 or bring it to your appointment.
The fields marked with (*) are required fields. |
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Today's Date * |
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Patient Name * |
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Patient's Date of Birth * |
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Parents/Legal Guardians * |
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Siblings |
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Referred by |
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Please tell me why you are seeking this evaluation at this time. * |
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Please tell me about prior psychiatric, medical, neurological, psychological, developmental or mental health evaluations your child has received, including any psychological or neuropsychological testing or medical workups. Please email, fax or mail copies of recent testing if available or bring to our first meeting if you are not sure what to send. |
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What medications, including doses and times, does your child take currently? Include psychiatric and medical and over the counter or alternative/complementary medications as well. |
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Please tell me about any medications that your child has taken in the past and, if you remember, the doses of the medicines, how long he/she took them, and why they were stopped. |
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Were there any health problems, toxic exposures or other concern during the pregnancy, delivery or neonatal period? Please describe delivery and baby's general health at birth. |
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How old was your child when he/she first walked? |
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How old was your child when he/she first talked? |
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Fully toilet trained (day and night)? |
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What was your child's temperament like as an infant and toddler: Easy Going? Colicky? Low energy? High Energy? Please describe. |
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Did your child have any problems with sleeping as an infant and toddler? If so please describe. |
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Did your child have any eating problems as an infant and toddler? If so please describe. |
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What concerns (if any) came up about your child's early development? Were Early Intervention Services recommended? If so please describe. |
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Is there any family history of psychiatric illness, developmental delays or substance abuse? If so please describe. |
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Please describe your child's current school setting and supports that he/she receives there. Please describe previous school settings and supports as well. Please mail, email, or fax copies of recent school evaluations if available or bring to our first meeting so that we may review. I do not need copies of the IEP. |
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Please describe your child's current sleep patterns. |
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Please describe your child's current eating and appetite patterns. |
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Please describe any problems that your child is having with sensory input or motor skills. |
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Please describe your child's leisure time activities and relationships with peers. |
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What do you see as your child's strengths? |
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Do you have concerns that your child may be using alcohol, tobacco, marijuana or other drugs? If so, please describe. |
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Is there any history or known physical or emotional trauma? If so please describe. |
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Please tell me about any medical problems that your child has or has had in the past, especially any neurological problems such as seizures or motor or vocal tics, head injury or headaches, chronic pain or weakness, or any history of heart murmurs or rhythm abnormalities. |
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Is there any family history of cardiac rhythm abnormalities or of sudden death in a family member or members, such as sudden cardiac death before the age of 50? If so please describe. |
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Is your child allergic to any medications? If so, which ones and what are the reactions? |
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Is there anything else that you think I should know about your child or the family that may be important in understanding him or her? |
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