Birth History/Past Medical History

Full term. No complications.

ED visits: laceration requiring stitches and an arm fracture after a fall.

No medications or allergies.

Review of Systems:

Negative. Sleeps well. He eats a normal varied diet.

Family History

Younger brother, Sam (3 years old), is “very busy.”

Father had a hard time in school, he was the “class clown,” and had trouble focusing.

The rest of the family history was negative.

Social History 

Ben lives with his mother, father, and 3 year old brother.

His mother has a Masters degree and his father has an MBA. 

His mother is the primary caregiver and does not work outside the home.

Extended family support exists in the area.

Birth History/Past Medical History

Unremarkable

Developmental History:

Oliver did not say his first words until 15 months. Now there are no speech concerns.

He achieved his other developmental milestones on time.

Review of Systems:

Negative

Family History

Paternal first cousin with ADHD

Social History 

Parents separated 6 months ago and the social situation has been very stressful. However, mother describes that Oliver has always been “out of control”.

Birth History/Past Medical History

Unremarkable

Developmental History:

Unremarkable

Review of Systems:

Negative

Family History

Jill’s mother describes herself as a “worrier” but no formal diagnosis.

Jill’s father completed high school, but had trouble with reading and received extra reading help in elementary school. He recalls his teachers telling his parents that he was “hyperactive”.

Social History 

Jill lives with her married parents and a younger sister, age 6, who is healthy.  Her parents describe their home life as good, with a lot of family activities together on the weekends since they both work full-time.  Her mother teaches English as a second language and her father works in construction.