Secure Pediatric Neurology History Form - Please do not use all caps.

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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 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. normal.
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
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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
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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
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LUNGS: All choices in the LUNGS section are NO. At least one answer is YES; please check the box(es) that apply.
cough wheeze
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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
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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
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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
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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
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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
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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
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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
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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
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 quietly after lunch
During class at school
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