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Secure Pediatric Neurology History Form - Please do not use all caps.
Patient`s Last Name*

Patient`s First Name:*

Date of Birth*

Grade

Sex*

This Form Filled Out By*

Your Relationship to the Child*

Referring Physician*

What are you concerned about with your child?*

PREGNANCY AND BIRTH HISTORY
Full Term or Premature?*

What happened during the pregnancy?*

Labor & Delivery/C Section*

How many pounds did the child weigh at birth? Enter 0 if you do not recall.

How many additional ounces did the child weigh at birth? Enter 0 if you do not recall.

Number of Days in the Hospital*

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*

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

Siblings with illnesses



Other Condition Not Listed

Siblings with illnesses



Other Condition Not Listed

SOCIAL HISTORY
Mother`s occupational status:*

Mother`s occupation

Father/Partner`s Work Status*

Father/Partner`s occupation

Parents` Marital Status*

SCHOOL HISTORY
Activity Level*
overactive. underactive. possessing a normal activity level. 

Grades Repeated

Grade Repeated

Homework

Friendships

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

TELEMEDICINE WAIVER, IF APPLICABLE

Waiver of In Person Exam
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. Fidgets with hands or feet or squrims in seat
Never or Rarely Sometimes Often Very Often 

3. Has difficulty sustaining attention in tasks or play activities
Never or Rarely Sometimes Often Very Often 

4. Leaves seat in classroom or in other situations in which remaining seated is expected.
Never or Rarely Sometimes Often Very Often 

5. Does not seem to listen when spoken to directly
Never or Rarely Sometimes Often Very Often 

6. Runs about or climbs excessively in situations in which it is inappropriate
Never or Rarely Sometimes Often Very Often 

7. Does not follow through on instructions and fails to finish work
Never or Rarely Sometimes Often Very Often 

8. Has difficulty playing or engaging in leisure activities quietly
Never or Rarely Sometimes Often Very Often 

9. Has difficulty organizing tasks and activities
Never or Rarely Sometimes Often Very Often 

10. Is "on the go" or acts as "if driven by a motor"
Never or Rarely Sometimes Often Very Often 

11. Avoids tasks (e.g., schoolwork, homework) that require sustained mental effort
Never or Rarely Sometimes Often Very Often 

12. Talks excessively
Never or Rarely Sometimes Often Very Often 

13. Loses things necessary for tasks or activities
Never or Rarely Sometimes Often Very Often 

14. Blurts out answers before questions have been completed.
Never or Rarely Sometimes Often Very Often 

15. Is easily distracted
Never or Rarely Sometimes Often Very Often 

16. Has difficulty awaiting turn
Never or Rarely Sometimes Often Very Often 

17. Is forgetful in daily activities
Never or Rarely Sometimes Often Very Often 

18. Interrupts or intrudes on others
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

Watching TV

Sitting, inactive in a public place (e.g., a theater)

As a passenger in a car

Lying down to rest in the afternoon

Sitting and talking to someone

Sitting quiewtly after lunch

During class at school

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