Parent Questionnaire

James D. Chandler, MD, FRCPC

Has you child ever been a victim/witness of either emotional, physical or sexual abuse? If so, please describe.

Include names, relationship to child, phone numbers

Choose

Male

Female

Parent Email

Please choose the option that applies. I am the ..

Legal Guardian/Caregiver with Full Custody

Legal Guardian/Caregiver with Joint Custody

Foster Parent

Other

Has your child been in trouble with the law?

Has your child attempted suicide? if the answer is yes, please provide the details.

Has the child taken medications? What dose? How long? Did it work? How well?

Is there anyone involved from Mental Health or Schools Plus?

Are there other Doctors involved? (pediatricians, Specialist at the IWK, etc)

Has anyone in the family had a similar problem or psychiatric problems?

What medical problems does your child have?

Does the child have any allergies that we should be made aware of? If so, please list them below.

Is Family & Children Services involved?

Address where the child lives

Who is the child's Family Doctor or Nurse Pratitioner?

Who has assessed the child so far? what was their diagnosis? What treatment did they provide? What was the result of the treatment?

Does your child appear to hear voices or see things that no one else does? Does he or she seem paranoid or have ideas about how things are that no one else has?

What school does your child attend?

Child's Name: *

Has your child ever been traumatized by someone or been involved in a bad accident or witnessed to people traumatizing each other.

What doctors, nurse practitioners, psychologists or counselors are involved in your child's care?

Describe the problem your child has, how long it has been going on and how it has affected life at home, school and with peers.

Child's Health Card Number

Child's Date of Birth

What pharmacy do you use?