Robert L. Lopno II, MS Ed,
Lopno & Associates
1521 East Highway 13
Burnsville, MN 55337
Family Questionnaire-Child and Adolescent
The purpose of the questionnaire is to obtain a comprehensive view of your child’s background. These records are necessary to provide a thorough understanding of your child’s issues/concerns. I request you complete these routine questions prior to your first visit to my office.
Case records are strictly confidential. No outsider is permitted to see your case record without your permission. If you do not wish to answer any of the questions, please write “Do not care to answer” in the area next to the question.
I. General Information
Client’s Name _________________________ Sex ____ Age ____ Birth Date _________ Address ______________________________________ Birthplace _________________ ______________________________________ Phone _____________________
Father’s Name ____________________________________
If not birth father, give relationship ___________________________________________ Address (if different from above) ____________________________________________
Mother’s Name ____________________________________
If not birth mother, give relationship __________________________________________ Address (if different from above) ____________________________________________
Legal custodian of child, if other than birth parents(s) ____________________________
Referring person or agency _________________________________________________ Address ________________________________________________________________
Name of person completing this form _________________________________________ Relationship to child ______________________________________________________
II. Child’s Current Problems
A. Describe the child’s current problems(s) (medical, behavioral, social) 1. _____________________________________________________________ 2. _____________________________________________________________ 3. _____________________________________________________________ 4. _____________________________________________________________
B. When did current problem(s) start or when did you first notice it/them?
C. What do you think is the cause of the current problem(s)? ______________________________________________________________________
D. Do you believe the child is aware of the problem(s)? YES NO If yes, how is this awareness expressed?______________________________________
E. Do mother and father agree on the existence or extent of the problem(s)? YES NO If not, please explain.
F. Has the child had problems other than the current one(s)? YES NO If yes, please specify: ____________________________________________________
F. What was done about these problems? ____________________________________ ___________________________________________________________________
III Child’s Health (Please provide details of any “yes” response)
A. What is the child’s current: weight _________ height _______________
B. Were there any unusual reactions to any immunizations? YES NO
C. Does the child have any allergies? YES NO
D. Has the child ever had a fever above 105 degrees? YES NO
E. has the child had fever more than five days? YES NO
F. Has the child had any significant accidents or injuries (any...
Please join StudyMode to read the full document