2022 Summer Circles Medical History

Summer Circles Program

Child/Adolescent Medical History
Legal Name*

First NameMiddle NameLast Name
Date Of Birth

MonthDayYear
Today's Date

MonthDayYear
Date
Presenting Problem
What are the primary concerns for this child/adolescent as it relates to mental health symptoms, or issues related to self-esteem, confidence, anger management, peer relationship issues or school issues that your child/adolescent struggles with?
List two (2) goals you would like to see your child accomplish by attending our Summer Circles program?
List 1-3 strengths of your child:
School Functioning: Education Classification
Name of School: Cornerstone Academy
Current Grade:blank
Regular Education Classification? Yes No
If no, what ISP services does your child receive?

School Proficiency - At, Below, or Above Grade Level?

Rows	Results
Reading Proficiency
Math Proficiency
Citizenship Proficiency
Science Proficiency
Writing Proficiency

Attendance Issues?

Not a problemIs a problemExplain problem:
Other academic school concerns (including performance/behavioral problems due to AOD use)?

No concernsI have concernsExplain concerns:
Describe your child's social functioning and school relationships
Does your child have special communication needs?

NoYesExplain needs:
Symptoms Checklist

Check all current problems
Does your child have special communication needs? As evidenced by:

No communication needsLoss of interest in activitiesEmpty feelingFatigue / loss of energyThoughts of harming selfHopelessnessWorthlessnessTrouble concentratingIndecisivenessRecurrent thoughts of deathFeeling sad or depressedOther, explain:
Is your child experiencing grief issues? As evidenced by:

No grief issuesLoss of loved one in the past yearOther, explain:
Is your child experiencing anxiety? As evidenced by:

No anxietyExcessive worryRestlessnessObsessionsMuscle tensionIrritabilityCompulsionsDifficulty breathingPounding heartExcessive checkingStrong fearsShakingExcessive hand washingOther, explain:
Is your child experiencing traumatic stress? As evidenced by:

No traumatic stressRecurrent/intrusive/distressing thoughts/imagesRecurrent dreams/nightmaresStartles easilyExposure to traumatic eventOther, explain:
Is your child experiencing anger/aggression? As evidenced by:

No anger/aggressionThreatens/intimidates othersInitiates fightsPhysically hurts peoplePhysically hurts animalsUse of weaponsOther, explain:
Is your child experiencing oppositional behaviors? As evidenced by:

No oppositional behaviorsLoses temperArguesDeliberately annoys othersBlames othersEasily annoyedAngry and resentfulSpiteful/vindictiveOther, explain:
Is your child inattentive? As evidenced by:

Not inattentiveDifficulty sustaining attentionTrouble finishing thingsDisorganizedEasily distractedForgetfulOther, explain:
Is your child impulsive? As evidenced by:

Not impulsiveDifficulty resisting impulsesTrouble waiting for their turnFrequently interruptsOther, explain:
Name of person completing this form:

First NameLast Name
Relationship to the child

ParentLegal Guardian
Signature of person completing this form

Clear
Today's Date

MonthDayYear
Date
Should be Empty:

Summer Circles Program

Symptoms Checklist