Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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) 1 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 2 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? 3 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: 5-31-11 4