The answers to the following questions will be very important to your child in the future. Please answer each question to the best of your ability. All information you provide is completely confidential. The purpose of these questions is solely for the present and future medical wellbeing of your child.
Please answer the following questions pertaining to mental health history:
Please complete the table below to indicate whether you or any of your immediate family members (mother, father, brother, sister, grandmother, grandfather, aunt, uncle, or children) currently have or have had any of the following medical conditions in the past.
For any of the following conditions where you select a ‘Yes’ response, please use the fields provided to indicate who currently has (or has had in the past) the specific medical condition, the age of onset for the condition, and whether any medications were prescribed for the condition. Please be as specific as possible. Below are a few examples.
If you or any members of your immediate family have any other medical conditions or diseases that are not on this list, please use the space below to let us know what they are.