Download PEDIATRIC REHABILITATION MEDICINE DEPARTMENT

PEDIATRIC REHABILITATION MEDICINE DEPARTMENT
SPASTICITY PATIENT INTAKE FORM
Date: ________________________________________
REFERRING PHYSICIAN
NAME
SPECIALTY
Phone #
Fax #
PATIENT INFORMATION
NAME:
DOB:
AGE:
ADDRESS:
Mothers Name
Fathers Name
DIAGNOSIS:
List Current Concerns/Presenting Problems:
List Specific Goals of Evaluations/Treatment:
List Current/Previous Treatment for Spasticity (muscle tightness, high muscle tone) if known and where:
(Such as botox, oral medications, therapies and surgeries)
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List Previous Evaluation/(Professional/Center/Date):
(Please provide copies of most recent evaluations if available.)
List Medical Conditions:
List Previous Surgeries:
List Any Significant Prenatal Or Birth History (Weeks Gestation, Birth Weight, Head Circumference,
APGARS):
Premature
IUGR or Small Size
C-Section Birth (planned)
Forceps or Vacuum Delivery
Gestational Diabetes
Oxygen or Ventilator at Birth
Full Term
Weeks Gestation
Emergency C-Section
Eclampsia
Infection
NICU – Duration in NICU ____
Low Birth Weight
Breech Birth
Vaginal Birth
Preeclampsia
Drug Use during Pregnancy
Other: ____________________
Developmental History
The child…at (Fill in the blanks and check appropriate boxes that describe your child)
Sat
____
months
years Crawled
____
months
Pulled Up To Stand
____
months
years Walked
____
months
Talked
____
months
years Dressed Self
____
months
Toilet Trained
____
months
years Fed Self
____
months
Met All Motor Milestones On Time
Was/Is Developmentally Delayed
Check Any Of The Following That May Apply To The Child:
Developmental Delay
Cognitive Delay
ADHD/Attention Deficit
Mental Retardation
Reading Difficulties
Speech/Talking Difficulties
Hearing Problems
Autism Spectrum
Behavior Challenges
Social Challenges
Difficulty Swallowing
Has A G Tube For Nutrition
Difficulty Gaining Weight
Constipation
Low Muscle Tone
Pain
High Muscle Tone
Fractures/Weak Bones
years
years
years
years
Learning Disability
Writing Difficulties
Vision Problems
Academic Challenges
Sensory Processing Disorder
Picky Eater
Coordination or Balance
Challenges/Clumsy
Seizures
Sleep Disturbance
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CURRENT FUNCTION
Communication (At what age did the child do the following?)
Say single words?
Put 2 – 3 words together in a phrase?
How many words does your child currently use?
Is the child difficult to understand at times?
What is the child’s primary way to make his/her wants
and needs known?
(e.g., sign language gestures, pointing, sounds, one or
two words, etc.)
Does the child use an augmentative communication
device?
Fine Motor Skills: (Check all that apply)
Does the child…
Reach For Objects
Transfer Objects From Hand To
Manipulate Toys Or Objects
Hand
Scribble
Write (if age appropriate)
Type (if age appropriate)
Does the child have consistent hand dominance?
Right
Left
No
Activities of Daily Living:
What self help skills does the child have? Please use the following letter code:
U = Unable
I = Independent
Dresses Self (Upper Body) ____
Toilets Self ____
Finger Feeding ____
Zips Zippers ____
Puts On Shoes ____
A = Needs Assistance
S = Needs Supervision Only
Dresses Self (Lower Body) ____
Brushes Teeth ____
Feeds Self With Utensils ____
Buttons ____
Pushes Wheelchair ____
Undresses Self ____
Washes Hands ____
Drinks From Cup ____
Snaps & Hooks ____
Gross Motor Skills: (Check all that apply)
Does the child…
Sits
Crawl Or Creep
Climb
Hops On One Leg
Jumps With Both Feet
Run
Kicks
Ride A Tricycle Or Bicycle
Go Up and Down The Stairs
Is Good Negotiating
Plays the following sports (may include adaptive sports):
Playground Equipment
Social/Academic History:
Name of School:
Grade:
Does the child have an IEP?
Does the child receive therapies through the school?
Yes
No
If yes, which ones:
PT
OT
ST
Vision
Is the child involved in extracurricular activities?
Yes
No
Describe (Such as adaptive sports, dance, music, art, etc.): __________________________________________
Who does the child live with?
Are there any other children at home?
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Current Services: (Frequency and Location)
PT:
OT:
Speech:
Vision:
Hippo Therapy:
Pool Therapy:
Other:
Equipment: (Check all that apply)
Wheelchair: ___Manual
___ Power
Crutches: Frequency of Use _________________
Stander: Frequency of Use __________________
Hand Splints: Frequency of Use ______________
Car Seat
Leg Braces:
AFO’s
SMO’s
KFO’s
Walker: Frequency of Use ___________________
Gait Trainer: Frequency of Use _______________
Positioning Device
SWASH Brace
Other
Other: Frequency of Use _______________________
Family History
Family members (parents, siblings, grandparents) with any of the following conditions:
Who? (parents,
siblings, grandparents)
What Condition?
Nerve Diseases:
Yes
No
Muscle Diseases:
Yes
No
Bone Problems:
Yes
No
Rheumatologic Diseases:
Yes
No
Genetic Conditions:
Yes
No
Cerebral Palsy:
Yes
No
Other:
Yes
No
Other:
Yes
No
Current Medications: (Include Doses and Frequency)
Allergies/Adverse Reactions:
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