Fusion Family Consulting
1700 Alma Drive, Suite 480
Plano, Texas. 75075
214-296-9365

Child and Adolescent Psychiatry New Patient Information Form

(Please fill out and return at or prior to first appointment)

Patient Demographic Information:
Chief Complaint: What is your primary reason for seeking psychiatric consultation?
History of Presenting Illness:
Past Psychiatric History:
Medical History:
Past Medications:
Name of Medication Dose Taken Reason Prescriber Comments (helpfulness/side effects)
Current Medications:
Name of Medication Dose Taken Reason Prescriber Comments (helpfulness/side effects)
Please comment on any substance abuse (drugs/alcohol).
What? When did you start? How much did you use? Last use? What did it do for you?
Please choose any that the patient has had and include dates as best you can:
Family History:
Family Psychiatric History:
Family Medical History:
Prenatal History:
Developmental History:
School:
Problem Behavior Checklist: Do you/your child have any of the following problems?