Child Medical History Questionnaire Legal Name (required) Preferred Name Date (if you are having troubles with the date not submitting use the following format yyyy/mm/dd) Your Email (required) Primary Care Physician Psychiatrist Date of Last Physical Examination (if you are having troubles ith the date not submitting use the following format yyyy/mm/dd) List health problems you are experiencing at the present time. List health problems or surgeries you have experienced in the past. List any upcoming or proposed surgeries that we should be aware of. List any upcoming or proposed medications, herbal remedies, over-the-counter medications or food supplements that you are currently taking: (include medication, dosage, what it's taken for and prescribing physician) Have you experienced any adverse reactions to medications? Please list the medication, the reaction and when you took it. List psychotropic medications you have taken in the past. List any hormone treatment you are presently taking. If you have received outpatient psychotherapy in the past, please list the names of those who have provided the service. If you have received inpatient treatment in the past for psychiatric or psychological treatment, list the location, dates of treatment and the diagnosis.