Cuestionario de psiquiatría para la familia
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1 Page 1 of 6 Boston Children s Hospital Outpatient Psychiatry Service Department of Psychiatry 300 Longwood Avenue, Boston, MA Tel (617) Cuestionario de psiquiatría para la familia Este formulario nos dará información acerca de su adolescente. Tiene preguntas acerca de su salud general, desarrollo y salud mental, e incluye preguntas sobre la salud de la familia cercana. El cuestionario se colocará en el historial médico. Para programar su cita, necesitamos recibir este formulario. Por favor, envíelo de una de las tres maneras siguientes: Fax: Correo electrónico: IntakeOffice@childrens.harvard.edu Correo postal: Boston Children s Hospital Outpatient Psychiatry Service Intake Office Department of Psychiatry 300 Longwood Avenue, Fegan 8 Boston, MA Por favor, conteste todo lo que pueda. Puede dejar preguntas en blanco. Si hay un profesional de la salud que pueda ver a su adolescente, le daremos una cita y en su primer consulta hablarán de este cuestionario. Fecha de hoy [Date] / / mbre del adolescente [Child/Adolescent Name] Fecha de nacimiento [Date of Birth] / / Persona que completa el formulario: [For the person completing this form] Firma [Signature] mbre [Name] Relación con el adolescente [Relationship to child/adolescent]: Madre [Mother] Padre [Father] Abuela [Grandmother] Abuelo [Grandfather] Otra [Other] Family Self-Report Questionnaire FINAL (Spanish - Simplified)
2 Page 2 of 6 ANTECEDENTES DEL EMBARAZO, EL PARTO Y EL PRIMER AÑO DE VIDA [Birth History] Durante el embarazo, la madre del adolescente: [During pregnancy, did the child/adolescent s mother] Se enfermó o tuvo un accidente? [Get sick or have an accident?] Tomó algún medicamento? [Take any medicine?] Tuvo depresión o estrés? [Have depression/stress?] Fumó? [Smoke?] Consumió alcohol o drogas? [Use alcohol or drugs?] El adolescente nació:[your child or adolescent was born] A término [On time] Antes de la fecha [Early] Después de la fecha [Late] Peso al nacer [Birth weight] El adolescente nació con algún problema médico? [Did your child have any medical problems at birth?] Cuando el adolescente era bebé (1-12 meses): [As an infant (1-12 months), your child/adolescent:] Le gustaba acurrucarse [Liked to cuddle] Era más activo que otros bebés [Was more active than other babies] Tenía cólicos [Had colic] Era quisquilloso o irritable [Was fussy/irritable] Tenía dificultad para dormir [Had trouble sleeping] Tenía problemas de alimentación [Had trouble feeding] ANTECEDENTES DEL DESARROLLO [Developmental History] Marque la casilla que mejor describa el momento en que el adolescente hizo cada una de las siguientes actividades por primera vez: [Check the box that best describes when your child did the following] Se sentó solo [Sat alone] Gateó solo [Crawled alone] Se puso de pie solo [Stood alone] Caminó solo [Walked alone] Dijo sus primeras palabras [Said his/her first words] Habló con oraciones [Talked in phrases] Típico [Typical] Antes [Early] Tarde [Late] Habló con oraciones [Talked in sentences] Fue al baño solo [Bowel trained] Controló la orina, durante el día [Bladder trained, day] Controló la orina, por la noche [Bladder trained, night] Se ató los cordones de los zapatos [Tied shoelaces] Montó en bicicleta [Rode Bicycle] Típico [Typical] Antes [Early] Tarde [Late]
3 Page 3 of 6 ANTECEDENTES SOCIALES [Social History] Número de personas que viven en su hogar (incluyéndolo a usted y al adolescente): [Number of people in your household, including your child/adolescent] Hubo grandes cambios u otras situaciones estresantes en la familia en los últimos 2 años (mudanza, divorcio, nuevo trabajo, barrera de idioma, etc.)? [Have there been any big changes or other stressful situations in your child/adolescent s family in the last 2 years (moving homes, divorce, new job, language barrier, etc)?] Tiene preguntas o preocupaciones con respecto a la identidad de género o la orientación sexual de su niño? [Do you have questions or concerns regarding the gender identity or sexual orientation of your child?] Grado en la escuela [Grade in school] Maestro(s) [Teacher(s)] mbre de la escuela [School Name] Teléfono de la escuela [School Phone] Recibe el adolescente servicios de educación especial? [Does your child/adolescent get special education services?] Ha repetido grado? [Has your child/adolescent ever repeated a grade?] Si contestó que sí, qué grado? [If yes, which grade?] Sufre acoso escolar? [Is your child/adolescent bullied at school?] lo sé [t sure] Cómo le va al adolescente con las siguientes actividades? [How does your child/adolescent do with the following?] Trabajo en clase [Schoolwork] Bien [Good] Regular [Average] Mal [Poor] Deberes [Homework] Bien [Good] Regular [Average] Mal [Poor] Comportamiento en la escuela [In-school behavior] Bien [Good] Regular [Average] Mal [Poor] Amistades [Friendships] Bien [Good] Regular [Average] Mal [Poor] Asistencia [Attendance] Bien [Good] Regular [Average] Mal [Poor] Practica alguna religión la familia del adolescente? [Does your child/adolescent s family practice religion?] Está el adolescente haciendo algo que a usted le parece peligroso? [Is your child/adolescent doing anything that you think is dangerous?]
4 Page 4 of 6 ANTECEDENTES PSIQUIÁTRICOS Y MÉDICOS DEL NIÑO Y LA FAMILIA [PAST/FAMILY PSYCHIATRIC & MEDICAL HISTORY] Si no sabe la respuesta a cualquiera de los puntos de esta lista, puede dejarlo en blanco aquí y preguntarle al terapeuta en su primera cita. [If you aren t sure about any of the items in this list, feel free to leave them blank here and ask your clinician for help in your first appointment.] Ansiedad [Anxiety] Trastorno por déficit de atención e hiperactividad (TDA, TDAH) [ADD/ADHD] Trastorno del espectro autista [ASD] Trastorno bipolar (enfermedad maníaco-depresiva) [Bipolar] Depresión [Depression] Retraso del desarrollo [Developmental delay] Trastorno de la alimentación [Eating disorder] Discapacidad intelectual [Intellectual disability] Discapacidad del aprendizaje [Learning disability] Comportamiento obsesivo/compulsivo [Obsessive/compulsive behavior] Trastorno de tics/de Tourette [Toruette s] Maltrato/negligencia [Abuse/Neglect] Problemas de conducta [Conduct problems] Oír voces o ver cosas que no son reales [Hearing voices/seeing things] Autolesión (por ej., cortarse, arrancarse el pelo) [Self-harm] Problemas para dormir [Sleep problems] Uso o dependencia de sustancias [Substance use/dependence] Intento de suicidio [Suicide Attempt] Ideas de suicidio [Suicidal thoughts] Problemas con los hábitos higiénicos [Toileting problems] Síntomas de trauma [Trauma symptoms] Niño o [Child/Adolescent] Madre del [Mother] Padre del [Father] Hermano del [Sibling] Otro pariente (tío, tía, abuelo) [Other relative]
5 Page 5 of 6 Síntomas físicos sin causa aparente [Unexplained physical symptoms] Tratamiento psiquiátrico [Psychiatric treatment] Hospitalización psiquiátrica [Psychiatric hospitalization] Problemas o procedimientos médicos [Medical problems/procedures] Niño o [Child/Adolescent] Madre del [Mother] Padre del [Father] Hermano del [Sibling] Otro pariente (tío, tía, abuelo) [Other relative] Medicamentos psiquiátricos previos: Complete esta tabla O lleve una lista de los medicamentos a su cita. [Prior psychiatric medications: Either fill out this chart OR bring a list of medications with you to your appointment.] mbre del medicamento [Name of Medication] Dosis [Dose] [Año en que comenzó] [ Aún lo toma?] Fue útil? [Helpful?] Profesionales de salud mental (anteriores y actuales): [Mental health clinicians (past and current)] mbre [Name] Número de teléfono [Phone number] Sigue con este terapeuta? [Currently seeing this clinician?] Sí Sí Sí Hay alguien más con quien usted considere conveniente que nos comuniquemos? Anote esta información aquí:[is there anyone else you feel it would be useful for us to contact? Please give this information here:] mbre [Name] Número de teléfono [Phone number] GRACIAS! [Thank you!]
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