1. Name:
First Name: Middle Name: Last Name:

2. Age: Choose one:
3-6 years
7-9 years
10-12 years
13-15 years
16-18 years
Over 18 years

3. Birthday:
Month Day Year

4. Gender:
Male
Female

5. Mailing Address:


Street Address

City: State: Zip Code:


Country (if other than U.S.)

6. Telephone Number: ()
Area CodePhone Number

First Name: Middle Name: Last Name:

Psychiatrist
Clinician
Parent
Stepparent
Other, please specify:

9. Mailing Address:
Same as Childs (completed above)
Other (please fill in address below)



Street Address

City: State: Zip Code:


Country (if other than U.S.)

10. Phone Numbers:
Home: ()
Work: ()
Fax: ()

11. Email Address:

12. Name of Person Completing this Survey:
Same as Above (contact person)
Other (please give your name)

III. Child's Information

13. Child's Present Setting
Living at Home
Hospital
Living within a Residential Center
Other, please specify:

14. Symptoms During Illness:
Choose all that apply
Delusions
Hallucinations (auditory, visual, tactile, olfactory)
Thought Disorder
Bizarre Behavior (including catatonia)
Social Isolation
Violence to people and/or objects
Poor Hygiene
Other, please specify

15. Previous Diagnosis/Diagnoses:
Choose all that apply
Schizophrenia
Schizoaffective Disorder
Schizotypal Disorder
Schizoid Features
Pervasive Developmental Disorder (including autism)
Major Depressive Disorder (depression)
Major Depressive Disorder (depression) with Psychotic Features
Bipolar Disorder
Bipolar with Psychotic Features
Attention Deficit Hyperactivity Disorder (ADHD)
Learning Disorders
Conduct Disorder
Tourettes Syndrome
Adjustment Disorder
Seizure Disorder
Post-Traumatic Stress Disorder (PTSD)
Oppositional Defiant Disorder
Obsessive-Compulsive Disorder (OCD)
Other, please specify

16. Trauma (if applicable):
Choose all that apply
Physical Abuse
Sexual Abuse
Witnessed Family Violence
Other, please specify

17. Significant Medical Problems:

18. Hosptilizations, Residential Treatment Centers, Partial Hospitalizations

20. Past Medications:
Choose all that apply
Clozapine (Clorazil)
Haloperidol (Haldol)
Thioridazine (Mellaril)
Trifluoperazine (Stelazine)
Benztropine (Cogentin)
Lithium
Thiothixene (Navane)
Chlorpromazine (Thorazine)
Risperidone (Risperidal)
Olanzapine (Zyprexa)
Antidepressants
Stimulants
Divalproex (Depakote)
Neurontin (Gabapentin)
Carbamazepine (Tegretol)
Sertindole (Serlect)
Ziprasidone
Quetiapine (Seroquel)
Other, please specify:

21. Antidepressants (current and passt, if applicable):
Choose all that apply
Fluozetine (Prozac)
Sertraline (Zoloft)
Paroxetine (Paxil)
Venlefaxine (Effexor)
Bupropion (Wellbutrin)
Imipramine (Trofranil)
Desipramine (Norpramin)
Amitryptaline (Elavil)
Nortryptaline (Pamelor)
MAO Inhibitors (Parnate, Nardil)
Other, please specify

22. Stimulants (current and past, if applicable):
Choose all that apply
Methylphenidate (Ritalin)
Dextroamphetamine (Dexedrine)
Pemoline (Cylert)
Tenerex
Adderal
Stattera
Other, please specify

23. Additional information relevant to the child's condition:

24. Current Doctor:
Name:
Duration child has been under their care:
Address:
Telephone:
Fax:
Email:

V. Survey Respondent Information

25. What is the respondent requesting?
Choose all that apply
Treatment
Information about Childhood Schizophrenia
Information about NIMH Childhood Schizophrenia Treatment Protocol
Other, please specify

26. Referred by:
AACAP
NAMI
Doctor
Newspaper
AACAP Letter to the Doctor
Other, please specify

27. Additional Comments: