Download Cerebral Palsy New Patient Form

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