James D. Chandler, MD FRCPC

General Psychiatry

Yarmouth Professional Building

615 Main St. Suite 315

Yarmouth, NS B5A 1K1 Phone 902-742-6661

Questionnaire for Non-Emergent Child and Adolescent Referrals to Dr. Jim Chandler

 

Child's Name________________________________________________________

Phone Number_________________________________________________

Parents Name_________________________________________________

You can mail this to our office address or e mail it. If you want to fax it, call my office for the number. The email address is Drjameschandlermd@hotmail.com

. Feel free to use another sheet of paper

  1. Please briefly describe the type of problem your Child has. Include how long it has been going on and how it has affected your child at home, with his friends, and at school.

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  2. Who has assessed this child so far? What was their diagnosis? What Treatment did they provide? What was the result of the treatment?

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  3. Has the child taken medications? What was the drug? What Dose? How long? What side Effects? Did it work? How well?

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  4. Does anyone in your family have a similar problem or other psychiatric problems?

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  5. What medical problems does your child have?

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  6. Has this child been in trouble with the law? Does he have a problem with substance abuse?

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  7. Is Family and Children Services involved?

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  8. Has your child attempted suicide? If yes, describe the details.

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  9. Does your child hear voices or see things?

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  10. Has your child been abused?