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Rady Children’s Hospital – San Diego 3020 Children’s Way San Diego, CA. 92123 PATIENT INFORMATION Name: MR#: DOB: MD: Finance: New Patient Information Patient Name: ______________________________________________ Date of Birth: _____________________________ Date:_____________________ Age:___________ Sex:_______________ Reason for visit: _____________________________________________________________________________ Referred by (please include phone number): _______________________________________________________ Primary Physician Name: _______________________________ Phone Number: _______________________ Other Physicians: Neurology: Yes No Last Visit:______________________________ Orthopedics: Yes No Last Visit:______________________________ Ophthalmology (Eye): Yes No Last Visit:______________________________ GI: Yes No Last Visit:______________________________ Pulmonology: Yes No Last Visit:______________________________ Psychologist/Psychiatrist:: Yes No Last Visit:______________________________ Dentist: Yes No Last Visit:______________________________ Other: Yes No Specialty/Last Visit:_______________________ If the patient is a female over the age of 18, do they have a OB/Gyn Physician? Yes No Last Visit:______________________________ MEDICATIONS: (Please list all medications including dosage that patient is currently taking-if applicable please attach the patients medication sheet): _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Rev: Sept 2016 BIRTH/DEVELOPMENTAL HISTORY: Birth Weight: ______________________ Type of Delivery(Vaginal, C-Section, etc.): ____________________ Premature? If so, how many weeks gestation: _____________________________________________________ Any complications during pregnancy, delivery or immediately post delivery? If so, what: ____________________ ___________________________________________________________________________________________ Is patient product of Multiple birth or infertility treatments? ____________________________________________ Child sat at:_______________ Child walked at:_______________ Child spoke at:_______________ SURGICAL/BOTOX HISTORY: (Please list all surgical/botox procedures the patient has undergone including type and date. If additional space needed, please attach information):_______________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ PAST MEDICAL AND FAMILY HISTORY: Has the patient or a relative had treatment for, or problems with the following (if yes, please describe in comments): PATIENT RELATIVE COMMENTS: (Pls. state which relative) Eyes, ears, nose, mouth, throat Lungs (asthma, breathing problems) Heart, blood vessels, high blood pressure Stomach, intestines, liver, pancreas, glands Bladder, kidneys, urinary system Bones, joints, tendons, ligaments, muscles Skin (eczema, psoriasis, infections) Endocrine (diabetes, growth hormone, thyroid) Blood disorders, Lymphatic disorders, Cancer Neurologic (spasticity, nerve problems, CP) Rev: Sept 2016 Psychiatric disorder, attention defecit problems Immune system problems, infections OTHER ISSUES/CONCERNS: Does the patient have any other issues/impairments including: Intellectual/School: ___________________________________________________________________________ Visual: ____________________________________________________________________________________ Hearing: ___________________________________________________________________________________ Speech: __________________________________________________________________________________ Respiratory: _______________________________________________________________________________ Cardiac: __________________________________________________________________________________ Gastrointestinal/Feeding: _____________________________________________________________________ Bowel/Bladder:______________________________________________________________________________ Sleep:______________________________________________________________________________________ Skin:______________________________________________________________________________________ Other: ____________________________________________________________________________________ SOCIAL HISTORY: Legal Guardian of Child: Mom Grade in school:_____________ Dad Other:_______________________________________ Name of School:_____________________________________________ Recreation/Sports:____________________________________________________________________________ ADAPTIVE EQUIPMENT: Does the patient use any adaptive equipment including: Equipment Problems/Questions/Concerns: Power wheelchair Manual wheelchair Stander Gait Trainer Bath/shower equipment Lift/transfer equipment Stroller Arm Braces/Splints Leg Braces/Splints/AFO’s Back brace Car seat Hospital bed Feeding/Support Chair Rev: Sept 2016 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Commode Equipment Other:______________ REHABILITATION SERVICES: Does the patient currently receive any of the following services (If yes, please state location and frequency): Physical Therapy None School MTU Childrens Hospital Other Location and Frequency:____________________________________________________________________ Occupation Therapy None School MTU Childrens Hospital Other Location and Frequency:____________________________________________________________________ Speech Therapy None School MTU Childrens Hospital Other Location and Frequency:____________________________________________________________________ If you wish to make any further comments please do so here: __________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ We would like to thank you in advance for completing this form. Rev: Sept 2016