Patient Symptom Checklist

Patient Symptom Checklist
LISTA DE COMPROBACION DE SINTOMAS DEL PACIENTE
What are the problems that caused you to seek help at Excel for the child?
Cuales son los problemas que provocaron que buscara ayuda en Excel para el nino/a?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
How long have you had these problems with the child? _______________________________________________________
Cuanto tiempo tiene con estos problemas?
MENTAL HEALTH TREATMENT HISTORY
HISTORIADE TRATAMIENTO DE SALUD MENTAL
OUTPATIENT/INPATIENT OR RESIDENTIAL CARE
PACIENTE EXTERNO/PACIENTE HOSPITALIZADO,
QUIDADO RECIDENCIAL
DATES
FECHAS
CURRENT PSYCHIATRIST______________________________ TELEPHONE#____________________
PSIQUIATRA ACTUAL
TELEFONO
CURRENT THERAPIST__________________________________ TELEPHONE #___________________
TERAPEUTA ACTUAL
TELEFONO
PAST PSYCHIATRIC MEDICATION HISTORY
HISTORIA DE MEDICINA
MEDICATION
MEDICAMENTO
PRESCRIBER
PRESCRIBIR
DATES
FECHAS
REASON FOR CHANGE/SIDE EFFECTS
RAZON PARE EL CAMBIO/EFECTOS
SECUNDARIOS
FAMILY MEMBERS MENTAL HEALTH/SUBSTANCE ABUSE TREATMENT HISTORY
SALUD MENTAL DE LOS MEIMBROS DE LA FAMILIA/TRATAMIENTO DE ABUSO DE SUSTANCIA
RELATIONSHIP
RELACION
DIAGNOSIS
DIAGNOSTICO
THE EXCEL CENTER
PARENT SYMPTOM REPORT
HOSPITLAIZATIONS MEDICATIONS
HOSPITALIZACIONES
PATIENT NAME
MEDICAMENTOS
Patient raised by /Quien crio al paciente___________________________________________________________
Patient currently living with/Con quien vive el paciente_________________________________________________
Others in the home/Quien mas vive en la casa________________________________________________________
______________________________________________________________________________________
Adopted/Adoptado: Yes/Si _______ No_______Age of adoption/edad de adopcion___________________________
Does child know/Sabe el nino/a?________________________________________________________________
Circumstances of adoption/Circunstancias relacionadas a la adopcion_________________________________________
______________________________________________________________________________________
Parents separated/Padres separados__________________Divorced/Divorciados_____________________________
Age of child at separation/Edad del nino/a en el tiempo de separacion_________________________________________
Custody arrangements/Arreglos relacionados a la costodia________________________________________________
______________________________________________________________________________________
HISTORIA RELIGIOSO:
Religious History: Child’s religion/Religion del nino/a_______________________________________________
Recent changes in religious beliefs?If so, explain/Cambios recientes de religion? Si la respuesta es si, por favor de explicar:______
_____________________________________________________________________________________
Any religious beliefs that may affect treatment?/Creencias religiosas que pueden afectar el tratamiento?__________________
______________________________________________________________________________________
Tickets/Citations/Arrests
Multa/Citacion/Detenciones
Legal History/Historia Legal
Dates
Fechas
Reason
Razon
Probation/Libertad condicional: Yes/Si________No/No____________________Any special conditions/Condiciones
especiales________________________________________________________________________________
Probation Officer: Name/Oficial de libertad condicional:______________________Tel/Tele#________________
Court Dates Pending/Fechas pendientes de corte:Date/Dia_____________Reason/Razon________________________
THE EXCEL CENTER
PARENT SYMPTOM REPORT
NAME
Depressive Symptoms
Sintomas Depresivos
Yes
No
Si
Depressed or irritable mood most of the day
Estado de animo deprimido o irritable la mayoria del dia
Severe decreased interest in pleasurable activities
Severa disminucion de interes en actividades placenteras
Trouble falling asleep, staying asleep, or increased sleep
Problemas para conciliar el sueno, permanecer dormido, o sueno
mayor
Noticeable restlessness or agitation
Notable inquietud o agitacio
Change in usual eating pattern; Less _____More_____
Cambio en su alimentacion;
Menos______Mas_______
Change in weight; Loss______Gain_______
Cambio en peso; Perdida _______ Aumento_______
Period of time_______________
Periodo de tiempo________________
Noticeable slow movements
Notables movimientos lentos
Expresses Feelings of worthlessness or excessive guilt daily
Expresa sentimientos de minusvalia o culpabilidad excesivo
diariamente
Decreased concentration or increased indecisiveness daily
Disminucion de concentracion o aumento de indecision
diariamente
Recurring thoughts of death or suicide
Pensamientos recurrentes de muerte o suicidio
Talks about dying or hurting him/herself
Habla de morir o lastimar a si mismo/a
Cutting on self /cortarse el mismo
Previous suicide attempt? /Intento de suicidio previo
THE EXCEL CENTER
PARENT SYMPTOM REPORT
NAME
Comments /additional thoughts
Comentarios/otros pensamientos
No
Anxiety Symptoms
Sintomas de ansiedad
Comments /additional thoughts
Comentarios/ otros pensamientos
Seems restless, edgy, keyed up
Parece inquieto, nervioso
Separation anxiety, school phobia
Ansiedad por la separacion, fobia a la escuela
Fear of strangers or new situations
Temor a extranos o nuevas situaciones
Obsessions/compulsions
Obsesiones y combulsiones
Persistent nightmares or flashbacks
Persistentes pesadillas o escenas retrospectivas
Physical complaints
Disfunciones fisicas
Refusal or reluctance to go somewhere due to fears
Negativa o renuncia a ir a algun lugar debido a los temores
Excessive fears about being alone
Excesivos temores acerca de la soledad
Child clings to you in public
Nino/a se aferra a usted en publico
Child refuses to go to sleep without you near
Nino/a se niega a ir a dormer sin usted estar cerca
Child throws tantrums to keep you from leaving him/her
Nino/a produce rabietas para mantenerlo cerca
Mood Disorder Symptoms
Sintomas de transtornos del Estado de animo
Complains of being bored / Se queja de ser aburrido
Yes/
Si
Complains of a lot of ideas at one time
Se queja de un monton de ideas al mismo tiempo
Has periods of excessive, rapid speech
Periodos de expression excesiva, rapida
Displays rapid, abrupt mood swings
Muestra cambio de animo rapida y repentino
Displays periods of hyperactivity
Muestra periodos de hiperactividad
Has irritable mood states
Tiene estados de animo irritable
Has excessively silly, giddy mood states
Tiene estados de animo excesivamente tonto, vertigo
Has exaggerated ideas about self or abilities
Exagera ideas acerca de si mismo o habilidades
Explosive temper tantrums or rages
Colera ( coraje ), hace berrinches
Has destroyed property intentionally
Ha destruido intencionalmente la propiedad
Curses viciously in anger
Maldice feroz en ira
Has physically assaulted another person
Ha agredido fisicamente a otra persona
Is fascinated with blood and gore
Esta facinado con sangre y gore
THE EXCEL CENTER
PARENT SYMPTOM REPORT
NAME
No
Comments/additional thoughts
Comentarios/ otros pensamientos
Other Issues /Otras cuestiones
Yes
/Si
No
Comments/ Additional thoughts
Comentarios/ Adicional pensamientos
Bedwetting, soiling self /Enuresis, suciedad en si mismo
Sexualized behaviors or sexually bizarre drawings
Comportamientos sexual o dibujos sexualmente bizarros
Sexually promiscuous, seductive or provocative
dress/behavior / Sexualmente promiscuo/a, sedutor/a o
Provocativo/a en el vestir/comportamiento
Unusual preoccupation with sexual acts or language
Inusual preocupacion con actos sexuales o lenguaje
Sexual acting out play with other children or animals
Sexual actuando a jugar con otros ninos o animales
Internet usage excessive; My Space, etc.
Uso de Internet excesivo; Mi espacio, etc.
Reports haring voices or seeing things
Reporta escuchando voces o ver cosas
Bizarre thoughts or behaviors
Pensamientos o comportamientos bizarros
Substance Use
Age at
first Use
Uso de la sustancia
Edad al
primer
uso
Drinks alcohol / Bebe alcohol
Smokes marijuana / Fuma marijuana
Use amphetamines (speed, ice, crank, etc…)
Uso de anfetaminas (velocidad, hielo, Crank, etc…..)
Uses cocaine or crack / Utiliza cocaine o crack
Uses inhalants (sniffs glue, paint, air freshener, gasoline,
markers, etc…) Utiliza los inhalants (huele pegamiento, pintura,
ambientador, gasolina, marcadores, etc……)
Uses ecstasy / Utiliza el extasis
Uses hallucinogens (LSD, mushrooms, heroin, etc…)
Utliza alucinogenos ( LSD, hongos alusinojenos, heroina, etc…..)
Uses sedatives (Valium, Xanax, Ativan, etc…)
Utiliza sedantes ( Valium, Xanax, Ativan, etc……)
Uses painkillers (Vicodin, Oxycontin, Soma,
hydrocodone, etc…) Utiliza analgesicos ( Vicodine,
Oxycontin, Soma, hidrocodona, etc…..)
Uses PCP / Utiliza el PCP
Abuses prescription drugs
Abuso de medicamientos recetados
Uses tobacco
Usa tabaco
If yes, what form?
If yes, what?
Si es si, que?
Si es si, que forma?
THE EXCEL CENTER
PARENT SYMPTOM REPORT
NAME
Date of
last Use
Fecha de
ultimo
uso
Frequency:
Frecuencia
Daily, Weekly,
Diario, Semanal,
Monthly, Mensual
Ocasional
Ocasionale
Amount
Used
Cantidad
utilizada
ABUSE HISTORY /HISTORIA DE ABUSO
Child’s Age
Abused By /Abuso
TYPE TIPO
Edad de nino
CPS Report
Made Informe
hechos a CPS
Emotional / Emocional
Neglect / Abandono
Physical / Fisica
Sexual / Sexual
Domestic Violence/Violencia Domesica
Educational History: Special Education; Yes____No____Learning Disability_______________________
Historia de educacion: Educacion Especial;
Si______No_____Dificultad de aprendizaje?_________________________
Suspensions: Yes_____No______Reason____________________________________________________
Suspensiones:
Si_______No________Razon________________________________________________________________
Alternative School Placement: Yes___No___Dates____________________________________________
Ubicacion en escuela alternative:
Si______No_____Dias_____________________________________________________
Reason / Razon__________________________________________________________________________
DEVELOPMENTAL ISSUES / CUESTIONES DE DESARROLLO
Normal pregnancy and delivery?______________________________________________________________
Embarazo y parto normal?
Difficulties at birth?_______________________________________________________________________
Dificultades al nacer?
Mother use of drugs or alcohol during pregnancy?__________________________________________________
La madre utilizo drogas o alcohol durante el embarazo?
Birth weight?____________________________________________________________________________
El peso al nacer?
Able to soothe as an infant?_________________________________________________________________
Capaz de calmar durante la infancia?
Sleeping all night at age?____________________________________________________________________
A que edad durmio toda la noche?
Crawled at age?__________________________________________________________________________
A que edad gateo?
Walked at age?___________________________________________________________________________
A que edad camino?
Talked at age?___________________________________________________________________________
A que edad hablo?
Appeared to have appropriate social skills for age__________________________________________________
Parecia tener habilidades sociales apropiadas para su edad?
Special Family Issues That May be Affecting Your Child / Problemas de familia en especial los que
pueden ser que afecten a su hijo/a?
______________________________________________________________________________________
______________________________________________________________________________________
Any other information you think is important for us to know / Cualquier otra informacion que cree
es importante que devamos saber?_________________________________________________________
THE EXCEL CENTER
PARENT SYMPTOM REPORT
NAME