It is important to know whether you have any of these symptoms presently, or have ever had them. If the symptom is not a current problem but you have had the symptom in the past, check the minor problem box.
Prenatal, birth events, and/or injuries such as stress, injury, drug exposure, difficult labor, forceps delivery, breech birth, induced labor, pitocin, anesthesia, anoxia, premature/late delivery, or post-birth problems? Other? Please describe.
Problems with growth and development such as severe or recurrent illnesses or infections, allergies, emotional difficulties, behavioral problems, appetite/digestion, language/speech, coordination? Walking or talking early? Walking or talking late? History of ear infections? Please describe.
Physical trauma, injury, coma, accidents, high fever, serious illness, surgery, CNS infection, poisoning, anoxia, stroke, heart attack? Have you ever been to the Emergency Room? Please describe.
Psychological stresses/life changes, especially during childhood such as a death, divorce, loss, move, school change, job change, illness? Did you experience emotional, physical or sexual abuse or neglect? Please describe.
Recreational drug use? If so, when, what drugs and how did each effect you? Have you ever had a drug overdose?