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Secure Pediatric Neurology History Form - Please do not use all caps.
IF YOU GET AN INVALID URL/ IMAGE SIZE ERROR & YOU ARE ATTACHING A FILE, IT COULD BE THAT THE FILE SIZE IS OVER THE 2.7 MB LIMIT.
Trouble submitting? Please fill out all items in the first section with an asterisk as they are required.
Please fill out as many of the nonrequired items as possible. The more information the better!
Patient`s Last Name*
Patient`s First Name:*
Date of Birth*
Grade
Choose a Grade
preschool
kindergarten
first
second
third
fourth
fifth
sixth
seventh
eighth
ninth
tenth
eleventh
twelfth
Sex*
Select from the following
boy
girl
young man
young lady
male infant
female infant
male toddler
female toddler
This Form Filled Out By*
Your Relationship to the Child*
Choose a Relationship
Mother
Father
Parents
Legal guardian
Stepmother
Stepfather
Grandmother
Grandfather
Aunt
Self
Referring Physician*
What are you concerned about with your child?*
PREGNANCY AND BIRTH HISTORY
Full Term or Premature?
Choose One
full term
two weeks late
one week late
one week early
two weeks early
three weeks early
four weeks early
five weeks early
six weeks early
seven weeks early
eight weeks early
nine weeks early
ten weeks early
eleven weeks early
twelve weeks early
thirteen weeks early
fourteen weeks early
fifteen weeks early
sixteen weeks early
seventeen weeks early
What happened during the pregnancy?
Select
One
normal pregnancy
pregnancy remarkable for high blood pressure
pregnancy remarkable for high blood sugar
pregnancy remarkable for infections
pregnancy remarkable for premature labor
pregnancy remarkable for maternal vomiting and dehydration
Labor & Delivery/C Section
Select
Labor & Delivery/C S
normal labor and delivery.
delivery via repeat cesarean section.
delivery via cesarean section due to failure to progress.
delivery via emergency cesarean section due to fetal distress.
delivery via cesarean section due to breech presentation.
How many pounds did the child weigh at birth? Enter 0 if you do not recall.
# pounds
1
2
3
4
5
6
7
8
9
10
11
12
How many additional ounces did the child weigh at birth? Enter 0 if you do not recall.
# ounces
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Number of Days in the Hospital
Select One
usual, not prolonged
3
4
5
6
7
8
9
10
20
more than 20
Did the baby come home with medications?
Yes
No
with a monitor?
Yes
No
Please Add Any Details re the Pregnancy, Labor, Delivery, and Time in the Hospital not covered above
PREVIOUS DIAGNOSES - CHECK ALL THAT APPLY
ADHD
seizures
asthma
concussion
febrile seizures
heart murmur
migraines
scoliosis
fractures
Tourette
stitches
fainting
hearing loss
glasses/contacts
frequent ear infections
sleep apnea
cerebral palsy
Other Condition or Explanation of Checked Item Above:
HOSPITAL ADMISSIONS SINCE BIRTH, SURGERIES, PROCEDURES including tonsils,adenoids, ear tubes
Any hospital admissions since birth, surgeries, procedures (eg, tonsils, adenoids, ear tubes) ?
Yes
No
DETAILS - SKIP IF NO HOSPITALIZATIONS, PROCEDURES, OR TESTS
TESTS: EEG
not done
normal
abnormal
CAT SCAN/MRI
not done
normal
abnormal
DEVELOPMENT
Development is/was
Select
Development is/was
normal
normal except for delays in speech
normal except for delays in fine motor skills
normal except for delayed walking
delayed in several areas
FURTHER DEVELOPMENTAL MILESTONES
Toilet Training
Is toilet trained.
Is not yet toilet trained.
Tricycle/Bicycle
Does not pedal a tricycle.
Rides a tricycle.
Rides a bicycle without training wheels.
Rides a bicycle with training wheels.
Shoe Tying
Ties shoes well.
Does not tie shoes.
Ties shoes loosely.
Handwriting
Possesses neat handwriting.
Has somewhat messy handwriting.
FAMILY HISTORY - PLEASE FILL IN DETAILS RE SEIZURES, HEADACHES, LEARNING DIFFERENCES, SUDDEN DEATH.
Seizure
Neither parent
Mother
Father
Both parents
Headache
Neither
Mother
Father
Both
Learning Difference
Neither
Mother
Father
Both
Inattentive As a Child
Neither parent
Mother
Father
Both parents
Has Relatives with Problems Similar to Patient
Neither
Mother
Father
Both
Has Relatives Who Died Suddenly/Unexpectedly?
Neither
Mother
Father
Both
Additional Information Re Mother and Mother`s Relatives
Additional Information Re Father and Father`s Relatives
Well Siblings
Select # of Well Siblings
3 siblings are alive and well
2 siblings are alive and well
1 sibling is alive and well
Siblings with illnesses
Select
Siblings with illnes
1 sibling has
2 siblings have
3 siblings have
Select Condition
migraines
seizures
asthma
allergies
ADHD
cerebral palsy
autism
Other Condition Not Listed
Siblings with illnesses
Select
Siblings with illnes
1 sibling has
2 siblings have
3 siblings have
Select Condition
migraines
seizures
asthma
allergies
ADHD
cerebral palsy
autism
Other Condition Not Listed
SOCIAL HISTORY
Mother`s occupational status:
Select
Mother`s Work Status
The mother does not currently work outside the home.
The mother is employed part time
The mother is employed full time
Mother`s occupation
Father/Partner`s Work Status
Select
Father`s Work Status
The father does not currently work outside the home.
The partner does not currently work outside the home.
The father works part time
The partner works part time
The father works full time
The partner works full time
The father is disabled.
The partner is disabled.
Father/Partner`s occupation
Parents` Marital Status
Select Parents` Status
The parents are married.
The parents are separated.
The parents are divorced.
The mother is raising the child on her own.
SCHOOL HISTORY
Activity Level
overactive.
underactive.
normal.
Grades Repeated
Was a grade repeated?
No grades have been repeated
Retention occurred in
Grade Repeated
Select
Grade Repeated
pre-K
kindergarten
first
second
third
fourth
fifth
sixth
seventh
eighth
ninth
tenth
Homework
Choose which option applies
Homework completion is not an issue.
Homework requires an adult`s presence but is not prolonged.
Homework is prolonged and requires an adult`s presence.
Homework is prolonged but does not require an adult`s presence.
Friendships
Choose which one applies
There is no difficulty with making or keeping friends.
Making friends can be difficult but maintaining friendships is not.
Making friends is not an issue but keeping friends is difficult.
There is difficulty with making and keeping friends.
Speech Therapy Frequency
Speech therapy occurs once per week
Speech therapy occurs twice per week
Speech therapy occurs three times per week
Speech therapy occurs four times per week
Occupational Therapy Frequency
Occupational therapy occurs once per week
Occupational therapy occurs twice per week
Occupational therapy occurs three times per week
Occupational therapy occurs four times per week
Physical Therapy Frequency
Physical therapy occurs once per week
Physical therapy occurs twice per week
Physical therapy occurs three times per week
Physical therapy occurs four times per week
Counseling Frequency
Counseling occurs once per week
Counseling occurs twice per month
Counseling occurs once per month
EDUCATIONAL ASSISTANCE:
ABA therapy is provided
Basic skills is provided
504 plan is in place
Resource room is provided
Individual aide is of assistance in the classroom
A shared aide is present in the classroom
Social skills is provided
Inclusion classes are provided
MEDICATIONS
Current Medications:
Previous Medications:
Allergies to Medications:
REVIEW OF CURRENT SYMPTOMS
GENERAL:
All choices in the GENERAL section are NO. Please go to the next ?.
At least one answer is YES; please check the box(es) that apply.
fatigue
fever
weight loss
weight gain
pale
_________________________________________________________________________________________________________________________________________________________________________________
EYES, EARS, NOSE, AND THROAT
All choices in this section are NO. Please go to the next question.
At least one answer is YES; please check the box(es) that apply.
trouble seeing
congestion
hearing loss
allergies
watery/itchy eyes
throat clearing
__________________________________________________________________________________________________________________________________________________________________________________
HEART:
All choices in the HEART section are NO.
At least one answer is YES; please check the box(es) that apply.
fast heart rate
chest pain
murmur
__________________________________________________________________________________________________________________________________________________________________________________
LUNGS:
All choices in the LUNGS section are NO.
At least one answer is YES; please check the box(es) that apply.
cough
wheeze
__________________________________________________________________________________________________________________________________________________________________________________
DIGESTIVE SYSTEM:
All choices in the DIGESTIVE SYSTEM section are NO.
At least one answer is YES; please check the box(es) that apply.
nausea
constipation
diarrhea
vomiting
stomach aches
___________________________________________________________________________________________________________________________________________________________________________________
ELIMINATION:
All choices in the ELIMINATION section are NO.
At least one answer is YES; please check the box(es) that apply.
up at night to urinate
urinary accidents
bowel accidents
urinates frequently
__________________________________________________________________________________________________________________________________________________________________________________
ENDOCRINE/HORMONES
All choices in the ENDOCRINE/HORMONES section are NO.
At least one answer is YES; please check the box(es) that apply.
decreased appetite
increased appetite
drinks too much
irregular periods
__________________________________________________________________________________________________________________________________________________________________________________
MUSCULOSKELETAL:
All choices in the MUSCULOSKELETAL section are NO.
At least one answer is YES; please check the box(es) that apply.
weakness
joint pain
cramps
falls
back pain
numbness
___________________________________________________________________________________________________________________________________________________________________________________
SKIN
All choices in the SKIN section are NO.
At least one answer is YES; please check the box(es) that apply.
rash
hair loss
birthmarks
itching
hives
__________________________________________________________________________________________________________________________________________________________________________________
NEUROLOGICAL
All choices in the NEUROLOGICAL section are NO.
At least one answer is YES; please check the box(es) that apply.
headache
tics
faints
double vision
staring spells
__________________________________________________________________________________________________________________________________________________________________________________
MOOD:
All choices in the MOOD section are NO.
At least one answer is YES; please check the box(es) that apply.
anxiety
depression
hallucination
irritable
stress
alcohol use
substance abuse
__________________________________________________________________________________________________________________________________________________________________________________
SLEEP:
All choices in the SLEEP section are NO.
At least one answer is YES; please check the box(es) that apply.
naps
leg pains
not awake a.m.
snores
apnea
up middle night
too sleepy
insomnia
OPTIONAL SCALES - PLEASE FILL OUT IF YOU HAVE CONCERNS REGARDING ATTENTION AND/OR SLEEPINESS
ADHD Rating Scale: Home Version - Some questions will sound like school but please answer for home
1, Fails to give close attention to details or makes careless mistakes in schoolwork
Never or Rarely
Sometimes
Often
Very Often
2. Has difficulty sustaining attention in tasks or play activities
Never or Rarely
Sometimes
Often
Very Often
3. Does not seem to listen when spoken to directly
Never or Rarely
Sometimes
Often
Very Often
4. Does not follow through on instructions and fails to finish work
Never or Rarely
Sometimes
Often
Very Often
5. Has difficulty organizing tasks and activities
Never or Rarely
Sometimes
Often
Very Often
6. Avoids tasks (e.g., schoolwork, homework) that require sustained mental effort
Never or Rarely
Sometimes
Often
Very Often
7. Loses things necessary for tasks or activities
Never or Rarely
Sometimes
Often
Very Often
8. Is easily distracted
Never or Rarely
Sometimes
Often
Very Often
9. Is forgetful in daily activities
Never or Rarely
Sometimes
Often
Very Often
10. Fidgets with hands or feet or squrims in seat
Never or Rarely
Sometimes
Often
Very Often
11. Leaves seat in classroom or in other situations in which remaining seated is expected.
Never or Rarely
Sometimes
Often
Very Often
12. Runs about or climbs excessively in situations in which it is inappropriate
Never or Rarely
Sometimes
Often
Very Often
13. Has difficulty playing or engaging in leisure activities quietly
Never or Rarely
Sometimes
Often
Very Often
14. Is "on the go" or acts as "if driven by a motor"
Never or Rarely
Sometimes
Often
Very Often
15. Talks excessively
Never or Rarely
Sometimes
Often
Very Often
16. Blurts out answers before questions have been completed.
Never or Rarely
Sometimes
Often
Very Often
17. Has difficulty awaiting turn
Never or Rarely
Sometimes
Often
Very Often
18. Interrupts or intrudes on others
Never or Rarely
Sometimes
Often
Very Often
19. Argues with adults
Never or Rarely
Sometimes
Often
Very Often
20. Loses temper
Never or Rarely
Sometimes
Often
Very Often
21. Actively defies or refuses to go along with adults` requests or rules
Never or Rarely
Sometimes
Often
Very Often
22. Deliberately annoys people
Never or Rarely
Sometimes
Often
Very Often
23. Blames others for his or her mistakes or misbehaviors
Never or Rarely
Sometimes
Often
Very Often
24. Is touchy or easily annoyed by others
Never or Rarely
Sometimes
Often
Very Often
25. Is angry or resentful
Never or Rarely
Sometimes
Often
Very Often
26. Is spiteful and wants to get even
Never or Rarely
Sometimes
Often
Very Often
27. Is fearful, anxious, or worried
Never or Rarely
Sometimes
Often
Very Often
28. Is afraid to try new things for fear of making mistakes
Never or Rarely
Sometimes
Often
Very Often
29. Feels worthless or inferior
Never or Rarely
Sometimes
Often
Very Often
30. Blames self for problems, feels guilty
Never or Rarely
Sometimes
Often
Very Often
31. Feels lonely, unwanted, or unloved; complains that "no one loves him or her"
Never or Rarely
Sometimes
Often
Very Often
32. Is sad, unhappy, or depressed
Never or Rarely
Sometimes
Often
Very Often
33. Is self-conscious or easily embarassed
Never or Rarely
Sometimes
Often
Very Often
I`M SLEEPY SCREEN FOR OBSTRUCTIVE SLEEP APNEA
I: Is your child often Irritated or angry during the day?
Yes
No
S: Does your child usually Snore?
Yes
No
L: Does your child sometimes have Labored breathing at night?
Yes
No
E: Ever noticed a stop in your child`s breathing at night?
Yes
No
E; Does your child have Enlarged tonsils and/or adenoids?
Yes
No
P: Does your child have Problems with concentration?
Yes
No
Y: Does your child often Yawn or is he or she often tired/sleepy during the day?
Yes
No
Modified Epworth Sleepiness Scale
How likely is the child to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to the usual way of life in recent times. Even if the child has not done some of these things recently, try to work out how they would have affected him or her. Use the following scale to choose the most appropriate number for each situation:
0 = would never doze
1 = slight chance of dozing
2 - moderate chance of dozing
3 = High chance of dozing
During reading or storytelling
Choose a number
0
1
2
3
Watching TV
Choose a number
0
1
2
3
Sitting, inactive in a public place (e.g., a theater)
Choose a number
0
1
2
3
As a passenger in a car
Choose a number
0
1
2
3
Lying down to rest in the afternoon
Choose a number
0
1
2
3
Sitting and talking to someone
Choose a number
0
1
2
3
Sitting quietly after lunch
Choose a number
0
1
2
3
During class at school
Choose a number
0
1
2
3
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