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Name:__________________________________ Myelomeningocele Program Intake Form MRN:___________________________________ (To be completed at first visit only) DOB:___________________________________ Visit Date:________________________________ Child’s Full Name: ___________________________________________________ Date of Birth:________________________________ Gender: Male This Section for Office Use Only Place Patient Label Here Female Parent/Legal Guardian Name:__________________________________________ Home Phone:______________________________________ Work/Cell Phone:___________________________________________ Primary Care Physician:________________________________________________________________________________________ Please list names of any other Medical Specialists that this child is currently seeing at Riley or elsewhere: 1._________________________________________________ 3.____________________________________________________ 2._________________________________________________ 4.____________________________________________________ Maternal Health and Birth History 1. Was the child? Premature 3. Was there a prenatal diagnosis made? Yes 3. Was there a prenatal repair performed? Late Yes No No If Yes, where:___________________________________________ 5. How many weeks was baby in the hospital after birth? __________________ Hospital or Birth Center _______________________________________________ Home Other:________________________________________________________ 7. Delivery Method: Vaginal C-Section 8. Did the mother have a difficult labor? Yes Breech Stuck in birth canal Cord around neck Other:___________________________________________ Forceps No___________________________________________________________ 9. Did the infant experience any of the following problems at birth? 2. Length of Pregnancy:____________________ weeks 4. Did you meet with specialists prior to birth? No Yes 4. Birth Weight: _________________________ 6. Location of Delivery: Full -Term Bruising Breathing Problems Jaundice Seizures Difficulty feeding Birth Defects Infection Brain/Ventricle Bleeding Other:__________________________________________________________________________________________________________________ 10. Mother’s Condition: # Pregnancies______________ 11. Mother’s Age: ______________ # Live Births__________________ 12. Father’s Age:______________ 13. Mother’s Health Conditions During Pregnancy (check all that apply): Vaginal Bleeding Thyroid Problems Cigarettes (# of packs per day:________) #Miscarriages___________________ Premature Labor Hypertension Vomiting Diabetes Recurrent Infections Alcohol (# of drinks per week:________) Drug Exposure Toxemia STD HIV Preeclampsia Other:_______________________________________________________________________________________ 13. Stresses During Pregnancy (physical and/or emotional):____________________________________________________________ 14. Please list any medications taken by mother before and/or during the pregnancy: Folic Acid Prenatal Vitamins Prescription:______________________________________________________________________________________________ Other_______________________________________:____________________________________________________________ Reviewed by: _______________________________________________________ A Date: __________________________________ Rev. 4/8/11 Myelomeningocele Program History of Present Illness Place Patient Label Here Name:_____________________________________ Person Completing this Form: Relationship to Patient: Foster Parent Hosp#:_____________________________________ Mother Father Legal Guardian Grandparent DOB:______________________________________ Visit Date:__________________________________ Other: This Section for Office Use Only What are your main concerns today? Clinician Notes For Office Use Only Specific Concerns (check all that apply)? Behavior Issues Refills/Medications Diet/Nutrition/Feeding G-tube Bowel/Bladder Shunt Tether Cord School Growth/Development Wound/Skin HPI: EPF: 1 – 3, D: 4, C: 4+ Location, Quality, Severity, Duration, Timing, Context, Modifying facts, Other signs & symptoms Chief Complaint:______________________________ Equipment Yes No G-tube GJ Would you like to talk to a Social Worker today? Diet & Nutrition 1. How does your child feed? By Mouth 2. Name of Formula/Milk ________________________________________ 3. How often does your child feed? ________________________________ 4. How much formula/milk at each feeding? _________________________ 5. Does your child drink anything else? _____________________________ 6. What solids does your child eat? Purees Table foods 7. Does your child? Cough Refuse Feedings Choke/Gag 8. Does your child spit up or vomit? Never Often 9. Does your child have textural difficulties with foods? Every Meal Yes No MEDICATIONS – PLEASE COMPLETE MEDICATION SHEET ______________________________________________________ ___________________________________________________________ ALLERGIES Does your child have any drug allergies? Yes No If yes, please explain: _______________________________________ Latex Allergy: Yes No Kcal/kg/day: Precautions CC/kg/day: Are your child’s immunizations up to date? Yes No Unsure B EQUIPMENT Is your child using any of the following? AFO’s SMO’s UCBL’s Twister Cables Walker Wheelchair Gait Trainer KAFO’s Name:__________________________________ HKAFO’s Forearm Crutches Visit Date:________________________________ Stander Parapodium This Section for Office Use Only Place Patient Label Here RGO Other:______________________________________________________________________ Clinician Notes For Office Use Only SERVICES 1. Is your child currently receiving any of the following services? Occupational Therapy Physical Therapy Speech Therapy Behavioral Counseling Developmental Therapy Hippo Therapy Aquatic Therapy Nutritional Therapy 2. Is your child presently in any type of school? Yes No Classroom Type: ___________________________________ School Name: Grade: Hours per Day: 3. Is there an IEP? Days per Week: Yes No 4. Has psychoeducational tesing been performed? 5. Are there difficulties with: Math Yes Reading Writing Science Spelling No Other:__________________________________________________ Home Care Agency 1. Is your child currently receiving Home Care Services? Supplies Nursing DME Names: _________________________________________________________ Mobility 1. Is your child mobile by: Growth and Development 1. Is your child doing any of the following: Crawl Drag/Army Crawl Reach for Objects Use Fork/Spoon Bear Crawl Scoot Scribble Use Single Words Cruise Roll Use Two Words Together Speak 2-3 Word Sentences Assistive Devices Walker Recite ABC’s Count Stander Forearm Crutches Recognize Letters/Numbers Stack Blocks Manual Wheelchair Power Wheelchair Copy Circles/Squares Write Letters/Numbers Gait Trainer RGO Assist with Dressing Assist with Personal Care Independent with Dressing Independent with Hygiene Language 1. How does your child let you know what he/she wants? Words Eye Gaze Facial Expressions Crying Pointing Assistive Device Reviewed by:__________________________________________________ C Date:_______________________ Name:__________________________________ Myelomeningocele Program Visit Date:________________________________ This Section for Office Use Only Place Patient Label Here Review of Systems Please review each item as it relates to your child’s health. Constitutional Gastrointestinal Negative Problems sleeping Anemia Significant weight gain/loss Recent fevers, chills or sweats Other_________________________ Neurological Negative Seizures or staring spells Headaches Dizziness/light-headedness Numbness or tingling Problems with concentration Irritability Other_________________________ Eyes Urinary and Bladder System Negative Vision loss or concerns Eyes crossing or lazy eye Nystagmus (eyes bouncing) Has your child had a vision test? No Yes If Yes, when?_________ Other_________________________ Musculoskeletal Respiratory Negative Cardiovascular Skin Negative Wheezing Snoring or noisy breathing with sleep Cough Stridor Tracheostomy Cpap/Bipap Oxygen Apnea (Breathing Stops) Reactive Airway/Asthma Other_________________________ Pulmonologist Negative Negative Eczema or rash G tube site or NG tube irritation Wounds Birthmarks Other_________________________ Endocrine Negative Thyroid problems Pubertal changes Menses No Yes If Yes, 1st period _________ Precocious puberty (premature puberty) Growth hormone Excessive sweating Excessive thirst and urination Feeling too hot or too cold Other_________________________ Safety/Other Heart problems/Congenital Defect Chest Pain Murmur Cardiac-Apnea Monitor Other_________________________ Cardiologist Negative Muscle weakness Tightness or stiffness in joints Pain in neck, back, arms, legs Muscle spasms or cramps Scoliosis/curvature of spine Joint pain or swelling Broken bones Receives Botox Other_________________________ Hearing loss or concerns Earache or discharge Has your child had a hearing test? No Yes If Yes, when?________ Difficulty swallowing Frequent or worsening choking/gag reflex Drooling Change in quality/pitch of voice Does your child see a dentist? No Yes If Yes, when?________ Other________________________ Negative History of bladder or kidney infections Spontaneous void Toilet Trained Catheterization: How often?____________ Vesicostomy Monti (Ileovesicostomy) Mitroffanoff (Appendicovesicostomy) Bladder Augmentation Other_______________________ Ears/Nose/Throat Negative Nausea and/or vomiting Diarrhea, or constipation Gastroesophageal reflux Abdominal pain G-tube/J-tube/GJ-tube Enema/Suppository Use MACE: Amount:____________ Frequency:___________ Other_______________________ Negative How does your child travel in a car? Forward Facing Car Seat Rear Facing Car Seat Booster Seat Seat Belt Tethered wheelchair Are there any smokers living in your home? Yes No Do you have concerns about safety in your home? Yes No ALL OTHERS NEGATIVE Reviewed by: ______________________________________________ D Date: ______________________________ Name:________________________________ Myelomeningocele Program Past Medical, Family, Social History Visit Date:_____________________________ FIRST VISIT – PLEASE FILL OUT COMPLETELY REPEAT VISIT – INDICATE ONLY CHANGES SINCE YOUR LAST VISIT Past Medical History This Section for Office Use Only Place Patient Label Here No Changes Since Last Visit dated _______________ Please check all that apply Illnesses: Seizure Disorder Asthma Pneumonia Other Illnesses/Medical Conditions:____________________ Past Surgeries: Ear PE Tubes G Tube Tonsils Removed Nissen Adenoids Removed VP Shunt Other: __________________________________________ _____________________________________________________ _____________________________________________________ Other Hospitalizations: __________________________________________________________________________________________ ___________________________________________________________________________________________________ Injuries/Fractures: ______________________________________________________________________________________________ Procedures and Tests (such as MRI, chromosomes):___________________________________________________________________ Social History No changes Since Last Visit dated _______________ Patients Parents are: Child Lives With: Both Parents Married Divorced Mother Other:_________________________________________ Separated Father Foster Parents Other # of others living in home:_________ # of Siblings:_______________ Ages and health of Siblings:__________________________________________________________ Mother Employed? Yes No If yes, Occupation:____________________________________________________________ Father Employed? Yes No If yes, Occupation:____________________________________________________________ Is the family currently receiving any of the following services? Childcare Provided by: Parents Family Medical History Relatives WIC SSI Home Daycare CSHSC Medicaid Waiver Babysitter/Nanny Medicaid Disability Daycare Center No Changes Since Last Visit dated _______________ Please indicate any history of the following illnesses among the patients immediate family by checking the appropriate box. Immediate family consists of parents, siblings, and grandparents only. ADD/ADHD Alcohol/Drug Abuse Allergies/Asthma Autism/Asperger/PDD Cancer Diabetes Genetic Conditions Growth Problems Heart Disease High Blood Pressure Kidney Disease Learning Problems Liver Disease Mental Illness Cerebral Palsy Seizures/Epilepsy Mental Retardation Neurological Disorder Thyroid Problems Other (please list): ___________________________________________________________________________________________ __________________________________________________________________________________________________________ Reviewed by: _______________________________________________ E Date: _______________________________ Rev. 4/8/11
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