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INCIDENT #1

 

Child A aged 9 

CHIEF COMPLAINT:  Blindness.

REVIEW OF SYSTEMS:  Unavailable.

PAST MEDICAL/SURGICAL HISTORY:  None.

FAMILY HISTORY:  Noncontributory.

CLINICAL IMPRESSION: Fussy eater.

DISPOSITION:  Discharged home.

Psychiatric Hospitalisations (include where, when, & for what reason):

 

Have you ever  had psychotherapy?

 

Have you ever had ECT?  

 

REPRODUCTIVE HISTORY:

Age of first period:

# Pregnancies:

# Miscarriages:

# Abortions:

Have you reached menopause?  Y /  N

At what age?

Do you have regular periods?      Y /  N

 

DO YOU EVER DREAM OF DESIRE?