HTTP://WWW.COLUMBIASMA.ORG
PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER
DARRYL C. DE VIVO, MD
PETRA KAUFMANN, MD
JUAN PASCUAL, MD, PHD
HARKNESS PAVILLION, SUITE 525
180 FT. WASHINGTON AVE., NEW YORK, NY 10032
PHONE: 212-342-0263, FAX: 212-342-6865
Patient and Family Provided Information (PFPI)
Page 1 of 7
PATIENT NAME
PATIENT INFORMATION
PATIENT DATE OF BIRTH
PATIENT’S SCHOOL GRADE
MRN
CONTACT INFORMATION
MOTHER ’S NAME(S)
FATHER’S NAME(S)
STREET ADDRESS AND APT #
STREET ADDRESS AND APT #
CITY, STATE, AND ZIP CODE
CITY, STATE, AND ZIP CODE
EMAIL ADDRESS
EMAIL ADDRESS
HOME TELEPHONE
HOME TELEPHONE
WORK TELEPHONE
WORK TELEPHONE
CELLULAR PHONE
CELLULAR PHONE
FAX
FAX
INSURANCE INFORMATION
INSURANCE COMPANY
POLICY NUMBER (OF CHILD)
PLAN
TELEPHONE NUMBER OF INSURER
REFERRING PHYSICIAN INFORMATION
MD NAME
TELEPHONE
STREET ADDRESS (INCLUDE OFFICE/SUITE #)
FAX
CITY, STATE AND ZIP CODE
EMAIL
I hereby authorize direct payment of medical benefits to ____________________________________ for services rendered by him/her in person.
I understand that I am financially responsible for any balance not covered by insurance. I hereby authorize ______________________________
to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits.
PATIENT’S (OR LEGAL GUARDIAN’S) SIGNATURE
DATE:
HTTP://WWW.COLUMBIASMA.ORG
PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER
DARRYL C. DE VIVO, MD
PETRA KAUFMANN, MD
JUAN PASCUAL, MD, PHD
HARKNESS PAVILLION, SUITE 525
180 FT. WASHINGTON AVE., NEW YORK, NY 10032
PHONE: 212-342-0263, FAX: 212-342-6865
Patient and Family Provided Information (PFPI)
Page 2 of 7
PATIENT NAME
COMPLETE ALL SECTIONS OF THIS FORM.
WHAT IS THE REASON FOR TODAY’S VISIT FOR EXAMPLE, (INCREASING UNSTEADINESS WALKING FOR LAST SIX MONTHS):
REVIEW OF SYSTEMS. Place a check mark in the ‘Normal’ checkbox if the child has no symptoms related to that system; underline any symptoms
that are present and add comments or additional symptoms in ‘Findings’.
SYSTEM
SYMPTOMS
CONSTITUTIONAL
NORMAL
FEVER, WEIGHT LOSS, FATIGUE, RECURRENT
INFECTION, UNUSUAL ODORS OF BODY FLUIDS
EYES
DOUBLE VISION, LOSS OF VISUAL ACUITY, BLURRING,
CATARACTS, STRABISMUS, NEED FOR GLASSES
NORMAL
EARS, NOSE AND
THROAT
NORMAL
RESPIRATORY
NORMAL
CARDIOVASCULAR
NORMAL
GASTROINTESTINAL
NORMAL
GENITOURINARY
NORMAL
INTEGUMENTARY
NORMAL
MUSCULOSKELETAL
NORMAL
PSYCHIATRIC
NORMAL
ENDOCRINE
NORMAL
HEMATOLOGICAL
AND LYMPHATIC
NORMAL
ALLERGIC
NORMAL
NEUROLOGICAL
NORMAL
HEARING LOSS, RINGING IN THE EARS, VERTIGO,
AURAL (EAR) DISCHARGE, INFECTIONS, CONGESTION,
HOARSE VOICE, DIFFICULTY SWALLOWING, DENTAL
SYMPTOMS
SHORTNESS OF BREATH, WHEEZE, COUGH,
COUGHING UP BLOOD, BLUE DISCOLORATION,
ALTERED PATTERN OR BREATHING.
CHEST PAIN, ABNORMAL RATE OR RHYTHM,
ABNORMAL BLOOD PRESSURE, SHORTNESS OF
BREATH, SWELLING OF ANKLES.
DIARRHEA, CONSTIPATION, NAUSEA, VOMITING,
RECTAL BLEEDING, BLACK, TARRY BOWEL MOTIONS,
WEIGHT LOSS OR GAIN, JAUNDICE, SPECIFIC FOOD
INTOLERANCE OR AVERSION
BLOOD IN THE URINE, PAIN ON URINATION,
LOIN PAIN, IMPOTENCE
DARK OR LIGHT PATCHES ON THE SKIN,
RASH, CHANGES IN HAIR OR NAILS
JOINT PAIN OR SWELLING, SMALL LUMPS
UNDER THE SKIN, SKELETAL DEFORMITIES
MOOD CHANGES, DELUSIONS, HALLUCINATIONS
SYMPTOMS OF THYROID, ADRENAL, ISLET CELL,
PARATHYROID DISEASE
{PALE APPEARANCE, LOSS OF ENERGY,
ENLARGEMENT OF LYMPH NODES, ABNORMAL
BLEEDING OR CLOTTING
RUNNING NOSE, EYES, OR
SKIN REDNESS OR SWELLING
ABNORMALITIES OF HIGHER FUNCTION (INCLUDING
SPEECH AND LANGUAGE), STRENGTH,
COORDINATION, SENSATION, DEVELOPMENT;
SEIZURES OR OTHER SPELLS; HEADACHES
FINDINGS
HTTP://WWW.COLUMBIASMA.ORG
PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER
DARRYL C. DE VIVO, MD
PETRA KAUFMANN, MD
JUAN PASCUAL, MD, PHD
HARKNESS PAVILLION, SUITE 525
180 FT. WASHINGTON AVE., NEW YORK, NY 10032
PHONE: 212-342-0263, FAX: 212-342-6865
Patient and Family Provided Information (PFPI)
Page 3 of 7
PATIENT NAME
EXERCISE INTOLERANCE, DARK URINE (COCA COLA
COLORED), MUSCLE TWITCHING, CRAMPING, MUSCLE
PAIN, MUSCLE STIFFNESS
NEUROMUSCULAR
NORMAL
PREGNANCY AND DELIVERY
LENGTH OF PREGNANCY (WEEKS)
DELIVERY METHOD (VAGINAL, VACUUM EXTRACTION, FORCEPS, CAESARIAN SECTION)
PLACE OF DELIVERY
BIRTH WEIGHT
FOLIC ACID BEFORE CONCEPTION
Y
USE OF ANTENATAL VITAMINS AND IRON
N
Y
N
X-RAYS, RADIATION EXPOSURE OR THERAPY (IF “YES,” PLEASE EXPLAIN)
INFECTIONS (IF “YES,” PLEASE EXPLAIN)
Y
N
PRESCRIBED MEDICATIONS (IF “YES,” PLEASE EXPLAIN)
Y
N
ALCOHOL/TOBACCO/DRUGS (IF “YES,” PLEASE EXPLAIN)
Y
N
DIABETES
Y
N
HIGH BLOOD PRESSURE
Y
N
OTHER PROBLEMS (IF “YES,” PLEASE EXPLAIN)
Y
N
LENGTH OF LABOR (HOURS)
APGAR SCORES
JAUNDICE
Y
RESUSCITATION
N
Y
N
ABNORMALITIES NOTED AT BIRTH (IF “YES,” PLEASE EXPLAIN)
Y
N
Y
N
HTTP://WWW.COLUMBIASMA.ORG
PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER
DARRYL C. DE VIVO, MD
PETRA KAUFMANN, MD
JUAN PASCUAL, MD, PHD
HARKNESS PAVILLION, SUITE 525
180 FT. WASHINGTON AVE., NEW YORK, NY 10032
PHONE: 212-342-0263, FAX: 212-342-6865
Patient and Family Provided Information (PFPI)
Page 4 of 7
PATIENT NAME
INTENSIVE CARE (IF “YES,” PLEASE EXPLAIN)
Y
N
DEVELOPMENTAL MILESTONES. Please check ‘normal’ if he or she attained the milestones in the range indicated; otherwise record the time the
milestone was attained with any comments.
MILESTONE [USUAL RANGE FOR TERM INFANTS]
REGARDS (LOOKS AT) TOY [NEWBORN]
TURNS TO SOUND [0-2 MONTHS]
HOLDS TOY [1-2 MONTHS]
TRIES TO REPEAT SOUNDS, COOS, BLOWS BUBBLES [2-4 MONTHS]
HOLDS WITH BOTH HANDS [4-5 MONTHS]
TRANSFERS HAND TO HAND [5 –6 MONTHS]
KNOWS OWN NAME, BABBLES – ‘BA, MA, GA’ [5-7 MONTHS]
REACHES WITH ONE HAND [4-7 MONTHS]
PINCER GRASP [7-12 MONTHS]
SITS ALONE AT LEAST 10-30 SECONDS [5-8 MONTHS]
STANDS HOLDING FURNITURE [6-12 MONTHS]
POINTS TO NOSE ON REQUEST, SAYS ‘MAMA, DADA’, REPEATS SOUNDS AND WORDS [8-12
MONTHS]
STANDS ALONE [9-16 MONTHS]
WALKS ALONE [9-17 MONTHS]
WALKS UPSTAIRS WITH HELP [12-23 MONTHS]
IDENTIFIES FAMILIAR OBJECTS, 10-50 WORDS [13-20 MONTHS]
JUMPS OFF FLOOR WITH BOTH FEET [17-30+ MONTHS]
WALKS UP STAIRS ALONE, BOTH FEET ON EACH STEP [19-30+ MONTHS]
UNDERSTANDS SIMPLE QUESTIONS, 50-75 WORDS, TWO WORD SENTENCES, STUTTERS [18-24
MONTHS]
PEDALS TRICYCLE, RUNS SMOOTHLY [4 YEARS]
NORMAL
TIME ACHIEVED OTHERWISE
HTTP://WWW.COLUMBIASMA.ORG
PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER
DARRYL C. DE VIVO, MD
PETRA KAUFMANN, MD
JUAN PASCUAL, MD, PHD
HARKNESS PAVILLION, SUITE 525
180 FT. WASHINGTON AVE., NEW YORK, NY 10032
PHONE: 212-342-0263, FAX: 212-342-6865
Patient and Family Provided Information (PFPI)
Page 5 of 7
PATIENT NAME
WALKS DOWNSTAIRS, CATCHES BOUNCED BALL, JUMPS ON ONE FOOT [5-6 YEARS]
PEDALS BICYCLE [7 YEARS]
SCHOOL PERFORMANCE
RECORD CURRENT AND PAST GRADES, INDICATING AREAS OF STRENGTH AND WEAKNESS
BEHAVIOR (DESCRIBE ANY CONCERNS):
MAJOR ILLNESSES/INJURIES/SURGERIES
DATE/AGE
ILLNESS/INJURY/SURGERY
TREATING PHYSICIAN/HOSPITAL
DRUG THERAPY (PAST AND PRESENT). List all prescribed medications, including dose and times; also list all vitamins, herbal and dietary
supplements and other substances including caffeine and alcohol.
NAME
DOSE
STARTED
ENDED (NOTE IF CURRENT)
IMMUNIZATIONS. If all completed without problems, write ‘Up-to-date’; otherwise, please specify immunizations given and any problems
encountered, or those missing and why.
ALLERGIES OR ADVERSE EFFECTS FROM MEDICINES. List name of medicine and describe effect; write ‘None’ if there is no history of such
events.
NAME OF DRUG OR ALLERGEN
EFFECT (E.G. RASH, ASTHMA)
DATE OF EVENT(S)
HTTP://WWW.COLUMBIASMA.ORG
PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER
DARRYL C. DE VIVO, MD
PETRA KAUFMANN, MD
JUAN PASCUAL, MD, PHD
HARKNESS PAVILLION, SUITE 525
180 FT. WASHINGTON AVE., NEW YORK, NY 10032
PHONE: 212-342-0263, FAX: 212-342-6865
Patient and Family Provided Information (PFPI)
Page 6 of 7
PATIENT NAME
FAMILY HISTORY. Include details of illnesses, including neurologic, learning or behavioral problems. Please include deceased members of the
family, with age and cause of death where known.
RELATIONSHIP
NAME(S) AND AGE(S)
ILLNESSES
BROTHERS AND SISTERS
MOTHER
FATHER
MOTHER’S FATHER
MOTHER’S MOTHER
FATHER’S FATHER
FATHER’S MOTHER
OTHERS
SOCIAL HISTORY. Who does the child live with? Please describe your family’s circumstances (all individuals living in the household and their
relationships to the patient and each other.
HTTP://WWW.COLUMBIASMA.ORG
PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER
DARRYL C. DE VIVO, MD
PETRA KAUFMANN, MD
JUAN PASCUAL, MD, PHD
HARKNESS PAVILLION, SUITE 525
180 FT. WASHINGTON AVE., NEW YORK, NY 10032
PHONE: 212-342-0263, FAX: 212-342-6865
Patient and Family Provided Information (PFPI)
Page 7 of 7
PATIENT NAME
SIGNATURE
PRINT NAME AND RELATIONSHIP
DATE
PHYSICIAN’S SIGNATURE
PHYSICIAN NAME
DATE