Parent Intake Form
Comprehensive Neuromuscular Center
3333 Burnet Avenue MLC #2021
Cincinnati, Ohio 45229
Phone: (513) 803-3000
Fax: (513) 803-3300
Patient Name:
Current age:
Street Address:
City:
Home Phone:
DOB:
Mother’s Name:
Street Address:
City:
Home Phone:
Email:
DOB:
Father’s Name:
Street Address:
City:
Home Phone:
Email:
DOB:
Guardian’s Name:
Street Address:
City:
Home Phone:
Email:
DOB:
/
/
State:
Cell Phone:
Zip Code:
/
/
State:
Cell Phone:
Parent Occupation:
/
Zip Code:
Occupation:
/
State:
Cell Phone:
Parent Occupation:
/
State:
Cell Phone:
Zip Code:
Occupation:
/
Zip Code:
Occupation:
Please list an emergency contact - someone who is a support to you and your child:
Name:
DOB:
/
/
Street Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Email:
Are there any privacy issues that we need to be aware of? Yes No
Who are the primary care givers and relationships?
Who else lives in the home?
Name
Relationship
Age
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Parent Intake Form
INSURANCE INFORMATION:
Do you have Insurance?
NO
YES (complete info below)
Is it an:
HMO
PPO Other
Have you verified that your insurance will cover your expenses here?
YES
NO (you will be responsible for payment for anything not covered)
Note:
Primary Insurance
Secondary Insurance
Insurance Co. Name
Subscriber Name
Subscriber SS #:
Policy ID #:
Group #
Phone #:
Effective Date
1. Are there any financial or health insurance issues that may make it difficult for you to come to this clinic? Yes
No
If so, please explain so we may help you to work this out prior to the visit.
2. Are there any transportation problems that may make it difficult for you to get to the clinic?
Yes No
If so, please explain so we may help you to work this out prior to the visit.
Patient Information
1. Has your child been treated at CCHMC? Yes
If so, CCHMC Medical Record Number:
No
2. Who referred you? (Please add contact info)
3. What are your concerns or questions that you want addressed when you come to the
Comprehensive Neuromuscular Clinic?
a.)
b.)
c.)
4.
Is your child able to walk?
Yes No
Does your child have trouble walking? Yes No
Is your child in a wheelchair?
Yes No
Do you or your child have any special needs that we need to be aware of?
5. To whom should we send our report (Please list primary care doctor and other healthcare providers):
Name
Address
Phone
Send to this
provider
Send to this
provider
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Parent Intake Form
Current Health
1. What is your child’s diagnosis?
2. How was the diagnosis made?
3. Does your child have any current illnesses or medical concerns other than the Neuromuscular problem for
which they are referred to us? Yes No
(please explain)
Current Height:
Current Weight:
Are your child’s immunizations up to date? Yes No
If no, explain
4. MEDICATIONS: (prescriptions, pain meds, OTC meds, vitamins, herbals)
Drug
Dose/Amt
Frequency/Route
Reason/How long (if steroid)
5. ALLERGIES/TYPE OF REACTION:
Type of Reaction: (rash, difficulty breathing, respiratory arrest, swelling)
Name:
Type of Reaction:
Medications:
Foods:
Latex:
6. DIAGNOSTIC INFORMATION
Previous Testing
Cardiology:
Endocrine:
Neurology:
Pulmonary:
Past Medical History
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Parent Intake Form
___________________________________________________________________________________
If you have questions or difficulty filling out this form please call us for assistance.
After completing this form, please mail or fax to:
Cincinnati Children’s Hospital Medical Center
Comprehensive Neuromuscular Center
c/o Wendy Bommer, RN
3333 Burnet Avenue MLC #2021
Cincinnati, Ohio 45229
Phone (513) 803-3000 Fax: (513) 803-3300
Email: NeuromuscularCare@cchmc.org
BEFORE WE CAN SCHEDULE AN APPOINTMENT, the form must be completed and the information listed
on this checklist must be received by us. Once we receive this information, a member of the center will contact
you.
CHECKLIST OF MEDICAL INFORMATION TO BE SENT TO
COMPREHENSIVE NEUROMUSCULAR CENTER
□
□
Copy of all insurance cards (front and back)
From your primary care physician:
 Growth charts
 Relevant medical history
 Immunization records
□
If your child has been in the hospital:
 All hospital discharge summaries
□
Medical Reports for any of the following tests that you child may have had:
 MRI scans
 X-rays
 EEG studies, electromyography (EMG) or nerve conduction studies
 Muscle or nerve biopsy
 Genetic (DNA) testing
 Blood or spinal fluid tests
 Sleep, swallowing or feeding studies
 Echocardiograms
 Reports of all prior specialists evaluations
 Neuropsychological Evaluation Report
If any of these were abnormal, then please bring the actual test (films, biopsy slides) to your child’s appointment.
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