(203) 661-2596 Fax (833) 941-0867 75 Holly Hill Ln. Ste 103 Mon–Fri: 8:00 – 5:00

GREENWICH MEDICAL PARTNERS

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Dr. Sandra Lithgow Dr. Sara B. Seidelmann Dr. Catherine Joyce Dr. Herbert Archer Dr. Danielle Greenman Dr. Caleb Moore Dr. Rebecca Stiritz

Medical Records

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About Record Release Physicians

All Physicians Dr. Sandra Lithgow Dr. Sara B. Seidelmann Dr. Catherine Joyce Dr. Herbert Archer Dr. Danielle Greenman Dr. Caleb Moore Dr. Rebecca Stiritz

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Dr. Rebecca Stiritz, Psy.D.

Child information form.

Fields marked * are required.

Referred ByName of Child *Date Of Birth *Sex *AddressCity *State *Zip Code *Home PhoneSchool & Current GradePediatricianMother’s NameAddressPhoneCellWorkOccupationFather’s NameAddressPhoneCellWorkOccupationParent’s Marital Status

Patient’s Siblings

Please list the names, ages, and dates-of-birth of the patient’s siblingsPayment OptionsCard NumberExp DateSec CodeReason for ReferralOther Concerns

Prenatal History

Were there any complications during pregnancy and/or delivery?How old were you when your child was born?

Were any of the following taken during pregnancy? (select all that apply)

beerwinealcoholcoffee/caffeineprescription medicationsherbal products

Child’s birth weight? Apgar score?Any health complications following birth?

Infancy

Were there any feeding, sleeping, responsiveness (alertness), or health problems during infancy?How active was your child as an infant?

Developmental Milestones

Age He/She Sat UpAge He/She CrawledAge He/She WalkedAge Word Spoke (other than mama/dada)Age Strung Words Spoke TogetherAge Toilet Trained

Medical History

Please check and describe any problems with the following:

HearingVisionGross Motor CoordinationFine Motor CoordinationSpeech, Articulation, Language processing

Has your child had any chronic health problems?

Has your child had any of the following:

head injuryconvulsionscomapersistent high fevers

Is there any history of physical, sexual, or emotional abuse?Does your child have difficulty sleeping at night?Does your child have any difficulties with eating or with his/her appetite?

Educational And Learning Concerns

How is your child performing at school currently with regard to reading, math, and other academic skills?At what grade level is your child functioning in reading and math?Any difficulty completing assignments in school or at home?Has your child ever had to repeat a grade?Is he/she receiving any educational support services either in or outside of school?Has your child’s teachers expressed concerns about him/her?

Please briefly describe your child’s experiences in:

PreschoolGrade SchoolMiddle SchoolHigh School

Peer Relationships

How does your child get along with his/her siblings?Does your child seek friendships with peers?Do peers seek friendships with your child?Briefly describe any concerns regarding peer-related problems

Psychiatric History

Has your child ever been evaluated by a mental health professional?Has medication ever been prescribed for psychiatric, behavioral, attentional, or learning purposes?Is there any family history of psychiatric, neurological, and/or learning disabilities in your extended family?Other Concerns or Issues

GREENWICH MEDICAL PARTNERS

A private medical practice serving Greenwich with the time and attention exceptional care requires.

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75 Holly Hill Lane, Suite 103
Greenwich, CT 06830
(203) 661-2596
Fax (833) 941-0867
Mon–Fri, 8am–5pm

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