Office Use
Ht:
cm (
%)
Child and Adolescent Neurology
 Wheelchair / Arm Span ________ cm
Patient Information Questionnaire
Wt:
Kg (
%)
FOC:
BP:
cm (
/
%)
Pulse:
/min. Temp
NKDA/Allergies:
Staff Initials: _________________
Today’s Date:
/
/
Please complete the following items. If in doubt, leave blank. Return this form with a
recent photo of your child to the front desk.
Patient Name:
Nickname:
Primary Care Physician:
Referring Physician:
Problem for which your child is being seen?
Age
DOB
/
Yr.
/
Mo.
What other concerns do you have?
Other current medical problems? (Allergies, Infections, Etc.):
Preferred Pharmacy: ___________ Pharmacy Phone Number: ____________
Who is completing this form?______________________________ Relationship to Patient______________________
Revised 3/13/15
1
Pregnancy History
Maternal age at delivery:
years
Illnesses during pregnancy, please list:
Medications or drugs used, please list:
Check if any of the following applies to you:
Alcohol
Incomplete pregnancies?
If yes, how many?
Other children:
Prescription Drugs
Recreational Drugs
Girls
Boys
Birth History
Hospital:
Place of Birth, City:
Duration of Pregnancy
Length of Labor
Check type of delivery:
Birth weight:
Apgar Scores:
1 min.:
Vaginal
hours
C-Section
Length:
5 mins.:
Due Date
Forceps
State:
Vacuum
Head size:
Neonatal History
Abnormalities noted at birth?
Breathe or Cry Immediately?
Feeding: breast or bottle
Special care given in the hospital?
How long was the hospital stay?
Developmental History
Gross Motor
Fine Motor
Rolled over
Months Reached
______
Sat alone
Transferred
______
Pulled to stand
_______
Ate w/ fingers
______
Crawled
_______
Used fork/spoon ______
Cruised
Undressed
______
Walked alone
_______
Dressed
______
Ran well
_______
Tied shoes
______
Pedaled tricycle
_______
Caught a ball
______
Pedaled bicycle
Scribbled
______
Left/Right handed
Pincer grasp
______
Expressive Language, Self Help
MaMa/DaDa
______
Laughed
______
Babbled
______
Single words
______
2 or more words ______
Name, age, gender ______
Learned colors
______
Potty Trained
______
Told Story
______
School History
Current School:
Present teacher’s name:
Special classes? __ If yes, what type:
Repeated grades? __ If yes, which grades, and at which schools?
Classroom performance?
Clubs, activities:
Special problems while attending school:
Receptive Language
Recognized Mom ______
Turned to voice ______
Understood “no” ______
1-step commands ______
2-step commands ______
Grade:
Current Medications (Name of medication & dose; prescription or non-prescription)
1.______________________________________
2.______________________________________
3.______________________________________
4.______________________________________
5.______________________________________
6.____________________________________
7.____________________________________
8.____________________________________
9.____________________________________
10.___________________________________
2
Past Medical History
Birthmarks
Yes
Allergies:
Yes
Asthma
Yes
Bedwetting
Yes
Clumsiness
Yes
Constipation/Diarrhea
Yes
Headaches
Yes
Unsuccessful past medication(s):
No
No
No
No
No
No
No
Head Injury
Yes
Hearing Problems
Yes
Heart Problems
Yes
Orthopedic problems
Yes
Reactions to
Immunizations
Yes
Speech Problems
Yes
Seizures/Convulsions
Yes
Unsuccessful past medication(s):
No
No
No
No
Vision Problems
No
Comments
No
No
No
Yes
For girls, age of first menstrual period:
Problems:
Hospitalizations or Operations
Regular?
Age
Where
1.
2.
3.
Is your child receiving?
Physical Therapy?
Occupational Therapy?
Speech Therapy?
Where?
Where?
Where?
Behavior Problems:
Short Attention Span
Poor Concentration
Sleep Problems
Eating Problems
Depressed
Compulsive
Oppositional
Previous Testing
Psychological Testing
EEG
CT Scan
MRI
Metabolic
Chromosomes
Fragile X
Hyperactive
Restless
Inattention
Destructive
Angry
Fearless
Head Banging
/
/
/
/
/
/
/
Distractible
Fidgety
Aggressive
Self-injurious
Anxious
Defiant
Rocking
Date
Impulsive
Talks out
Violent
Fire Setting
Obsessive
Dangerous
Lacks Remorse
Results
/
/
/
/
/
/
/
3
Enuresis
Encopresis
Temper Tantrums
Noncompliant
Sibling Problems
Peer Problems
Excessive crying or upset
Pica
Lies
Cruel to Animals
Steals
Truant
Family History
Child lives with:
Biological Father:
Highest Grade Completed:
Medical Problems:
Biological Mother:
Highest Grade Completed:
Medical Problems:
Other family members on medications?
Occupation:
Occupation:
Height
Age
Height
Age
If yes, list medication and family member
Please identify any family members with any of the following:
Cancer
Poor Coordination
Cerebral Palsy
Psychiatric Disorder
ADD/ADHD
Panic Attacks
Bipolar________________________________
Other:_________
Stroke
Epilepsy
Headaches
Hearing Loss
Depression
Mental Retardation
Seizures
Migraine
Vision Loss
Tic or Movement Disorder
Anxiety Disorder
Sleep Problems
______________
Obsessive-compulsive Disorder_________________
___________________________________
For Physician Usage
4
For Physician Usage
General Exam:
Appearance:
Skin:
Resp/Chest:
Extremities: Edema/Pulses
Abdomen
EENT Neck
Eyes
Heart
GU
Back
Mental Status:
Cranial Nerves I, III-XII
2nd Cranial Nerve Fundus:___________
Muscle Tone Bulk Strength
DTRs (see above)
Sensation
Cerebellum / Coordination:
Gait:
Neurologic Exam:
Fields
Color
Acuity: OS
OD
Tests Ordered/Reviewed:
Assessment:
Plan:
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
= 1 – 5 elements identified by a bullet
= At least 6 elements identified by a bullet
= At least 12 elements identified by a bullet
= Perform all elements by a bullet and document at least 2 elements identified by a bullet from each of nine
areas/systems
Counseling:
min.
Level
2 = 10 min;
1 = 5 min;
Total Visit:
3 = 15 min;
min. (Document time and summarize if > 50% of visit)
4 = 25 min;
5 = 40 min;
Signature
Date
5
Child and Adolescent Neurology
Date of Service
Patient Label or MRN, Patient Name, DOB,
REVIEW OF SYSTEMS
Please answer the following questions about your child’s present health
YES
NO
COMMENTS
Eyes
Head
Ears, Nose & Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurological
Psychiatric
Immunologic
Sleep
Tests
Blurring or Loss of vision? Eye surgery
Headaches?
Head injuries?
Hearing difficulties? Ear surgery?
Ear infections?
Chest pain?
Heart palpitations?
Heart murmur?
Rheumatic fever or Lyme disease?
Swollen ankles
Sore throats?
Nosebleeds, runny nose, sinus infections
Problems breathing through nose?
Spitting up blood
Any problems with teeth, gums, or
sores in the mouth?
Problems with shortness of breath?
Chronic cough or wheezing?
History of pneumonia?
Exposure to TB?
Chest X-rays?
Does your child eat poorly?
Chronic diarrhea?
Recent weight change?
Frequent vomiting?
Chronic constipation?
Problems urinating?
Blood in the urine?
Urinary tract infections?
Discharge from the penis or vagina?
Has your child’s menstrual cycle started?
Are her periods painful or irregular?
Is she using birth control?
Muscle or joints that are swollen?
Weakness? Cramps?
Any body parts that do not move freely?
Rashes?
Skin markings or birth marks?
Learning problems?
Attention problems?
Failing grades or classes?
Loss of skill or function?
Moody? Anxious?
Antisocial? Angry?
Obsessive? Compulsive?
Sad? Depressed?
Sleep problems?
Are your child’s immunizations up to
date?
Sleep walking? Night Terrors?
Bedwetting?
Has your child had any tests done since
their last visit? If so, please list.
Learning readiness/barriers identified per protocol:
Staff Initials:__________________
Reviewed and discussed with parent/legal guardian
_________________________________________Physician
_________________________________________Date
6