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HOW TO PREPARE FOR YOUR CHILD’S EVALUATION PATIENT PACKET If packet is not received 2 days prior to the child’s appointment, you will be asked to reschedule. Your appointment time has been reserved for you. If you are unable to keep this appointment time, you must notify the office 48 hours in advance in order to reschedule. A “No Show” fee of $50.00 will be billed if you miss the initial evaluation appointment without prior notice. Should you have any questions or concerns, please call our office. Dr. Annelise Spees, M.D., FAAP Doctor’s Medical Group of Colorado Springs 3210 North Academy Blvd., Suite 3 Colorado Springs, CO 80917 Phone: 719-531-0409 Fax: 719-531-0410 GETTING READY Consider what your concerns are at the moment. Typically, these concerns reflect problems with your child’s behavioral, emotional, family, school, or social adjustment. Take time to answer the following questions in areas that may be of concern to you. 1. What most concerns you now about your child? (Major problematic areas.) It helps to first identify whether they are mainly problems at home, in school, in the neighborhood or community, with other children, or in all of these areas. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 1 2. Please list anything that comes to mind that your child has difficulties with that might indicate a problem in these areas: Health (chronic or reoccurring medical problems) _____________________________________________________________________ _____________________________________________________________________ Intelligence or Mental Development____________________________________ _____________________________________________________________________ _____________________________________________________________________ Motor Development and Coordination__________________________________ _____________________________________________________________________ _____________________________________________________________________ Problems with Senses (such as eyesight, hearing, etc) ____________________ _____________________________________________________________________ _____________________________________________________________________ Academic Learning Abilities (such as reading, math) ______________________ _____________________________________________________________________ _____________________________________________________________________ Anxiety or Fears ___________________________________________________ _____________________________________________________________________ Depression _______________________________________________________ Aggression toward Others ___________________________________________ Hyperactivity _____________________________________________________ Poor Attention ____________________________________________________ Antisocial Behavior (such as lying, stealing, setting fires, running away) _____________________________________________________________________ * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 2 If taking medications for any of these concerns please note:_____________________ _____________________________________________________________________ 3. Are there any concerns that may be embarrassing to bring up at the visit? These often involve family problems that the parents believe may be contributing to their child’s behavioral or emotional problems. The more complete the background information, the better we can understand your child, so please note your concerns below. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 4. If at all possible, speak with your child’s teachers before the visit. Please write down their main concern regarding your child here. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ 5. Sometimes daily life stress can impact your child, such as job, housing, relatives, illness, etc. Please list any problems you think are occurring in your family that might help us better understand your child better. _________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ These lists should help to focus the evaluation quickly on the most important areas of concern that you have about your child and your family. They will also probably help speed up the evaluation and keep things on track. Finally, these lists will help to maximize the usefulness of the evaluation for you and your child. * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 3 THE EVALUATION The clinical interview with you, the caregivers, and with your child is the most important component of a comprehensive professional evaluation of a child. Other important elements are your completed behavior questionnaires about your child, similar behavior questionnaires completed by his/her teachers, and a thorough physical examination of your child. WHAT INFORMATION WILL WE NEED FROM YOU TO DO THE EVALUATION? Before professionals can identify or diagnose a child as having developmental behavioral, emotional, or learning problems, they must collect a great deal of information about the child and family. The professional must sift through this information looking for the presence of any psychological disorders, determine how serious the problems are likely to be, rule out or rule in other disorders or problems the child might have, and consider what resources are available in your area to deal with these problems. Please bring any school records and medical records you may have. IEP reports, labs, x-rays, and other consultations are very helpful. WHAT ELSE IS NEEDED TO COMPLETE THE EVALUATION? You may be asked to: (1) Give your permission for the professional to get the reports of previous evaluations that you child may have been given. (2) Permit the professional to contact your child’s treating physician for further information on health status and medications. (3) Provide results of the most recent educational evaluation from your child’s school. (4) Initiate one of these school evaluations, if one was not already done, and if one of your concerns is your child’s school adjustment. (5) Give your permission to have your child’s teacher(s) complete similar behavior questionnaires. (6) Give permission for the professional to obtain any information from social service agencies that already may be involved in providing services to your child. If you have already had an evaluation by the school or another professional with which you strongly disagree, you may want to tell us not to obtain the records from the other professional or school evaluation. Should you do so, please explain why you are withholding your permission for the release of these sources of information. If you disagree with what a teacher may say, explain to us so we can keep this disagreement in mind as we speak with the teacher. We always “consider the source” when reviewing reports completed by the people in a child’s life. * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 4 WHAT HAPPENS ON THE DAY OF THE APPOINTMENT? The Parent Interview The interview with you serves several purposes: (1) Establishes an important working relationship between you and Dr. Spees. (2) Provides an important source of invaluable information about your child and family. (3) Can often reveal just how much distress the child’s problems are causing you and your family. (4) Reveal significant information about your relationship with your child that could be important in pinpointing some potential contributors to your child’s problem. Two of the most important purposes are to determine a diagnosis of your child’s problem(s) and to provide you with reasonable treatment recommendations. The Child’s Interview Dr. Spees will be observing your child’s appearance, physical features, habits, communication style, reactions to the staff, and overall health throughout the visit. Much can be learned about your child by watching play, interactions, even upsets and tantrums. Please realize that whether your child is calm and cooperative or even having a tantrum, our visit is providing many clues to your child’s daily life experiences and possible diagnosis. We will provide paper, toys, and books to try to make the visit enjoyable while learning about your child. Your child is probably going to be asked a lot of general questions. These will probably deal with the following areas: (1) What is your child’s awareness of why he/she is visiting the interviewer today and what have the parents told him/her about the reason for the visit? (2) What are the child’s favorite hobbies, television shows, sports, or pets? (3) Where does the child attend school, who are his/her teachers, what types of subjects does he/she take in school, and which does he/she like most? If the child is doing poorly in a subject, what reasons does he/she give to explain any such difficulties? (4) Does the child see him/herself as having any behavior problems in the classroom? What types of discipline does the child get from the teacher(s) for any such misconduct? (5) How does the child think other children at school accept him/her? (6) What are you child’s perceptions of any of the problems that you have reported to the professional? (7) What would your child like to see changed or improved at home or at school? (8) The professional may then ask your child about whether he/she sees him/herself as having any behavioral problems. If the child does, he/she will likely be asked why and what he/she thinks causes this pattern. We hope you have found this information useful in preparing for your child’s evaluation with our professional staff. * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 5 CHILD AND FAMILY INFORMATION Child’s name ___________________________ Birth date ___________ ____ Age ________ Address _____________________________________________________________________ (Street) (City) (State) (Zip) Home Phone ( _____ ) ____ - ________ Parent Work Phone ( _____ ) ____ - _______ Is child adopted? Yes No If yes, age when adopted _____________________________ If yes, does the child know he/she is adopted? Yes Are parents married? Yes No Separated? Yes No No Divorced? If parents are separated or divorced, is there shared custody? Yes Yes No No Father’s name ____________________ ________ Age _____ Education (Years) ___________ Father’s place of employment ____________________________________________________ Type of employment ___________________________________________________________ If separated and shared custody, father’s address:____________________________________ (Street) _________________________________________________________________________________________________________ (City) (State) (Zip) Mother’s name ____________________ _________ Age _____ Education (Years) __________ Mother’s place of employment ___________________________________________________ Type of employment ___________________________________________________________ If separated and shared custody, mother’s address:___________________________________ - (Street) _________________________________________________________________________________________________________ (City) (State) (Zip) Can we share medical information with each parent? Yes No * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 6 Child’s school _____________________________ Teacher’s name ______________________ School Address _______________________________________________________________ (Street) (City) (State) (Zip) School Phone ( ____ ) ____ - ________ Child’s Grade_____________________ ______ Is child in special education? Yes No If so, what type? ____________________________ Name of child’s physician _______________________________________________________ Physician’s telephone number ( ____ ) _____ - ______ Physician’s address ____________________________________________________________ (Street) (City) Can we share information with this provider? Yes (State) (Zip) No PLEASE LIST ALL OTHER CHILDREN IN THE FAMILY Name Age Grade in school ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ PLEASE LIST ALL (CHILDREN, ADULTS, ETC.) INDIVIDUALS THAT ARE LIVING WITH THE CHILD ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 7 PEDIATRIC HISTORY PREGNANCY AND DELIVERY Length of pregnancy (in weeks)? _________ How many hours of active labor? ____________ Mother’s age when child was born? ______________ Child's birth weight: _________________ DID ANY OF THE FOLLOWING OCCUR DURING PREGNANCY OR DELIVERY? Bleeding excessively? ______________ Excessive weight gain (over 30 lbs)? ______________ Did Toxemia or Preeclampsia occur? ______________________________________________ Did frequent nausea or vomiting occur? ____________________________________________ Did serious illness or injury occur? ________________________________________________ Did you take prescription medications during the pregnancy? ___________________________ If yes the name of the medications: ________________________________________________ Did you use illegal drugs or drink alcohol during or before pregnancy? ____________________ Did you smoke cigarettes or chew tobacco during or before pregnancy? ___________________ If yes, approximate number of cigarettes per day? ____________________________________ Was given medication to ease labor pains? _________________________________________ Name of medication: ___________________________________________________________ Was the delivery induced? _______________________________________________________ Were forceps used during delivery? _______________________________________________ Was the child delivered in a breech position? ________________________________________ Did you have Natural birth or C-Section delivery? _____________________________________ Did you have to receive a Rhogam shot? ___________________________________________ LABOR AND DELIVERY HISTORY Was the child injured during delivery? ______________________________________________ Did the child go into cardiopulmonary distress during delivery? __________________________ Did the child have trouble breathing following delivery? ________________________________ Did the child need oxygen? _____________ Was the child cyanotic? _____________________ Was the child jaundiced? _______________ If so, was phototherapy used? Yes No Did the child have any infections? ________ Born with a congenital defect(s)? ______________ Was in hospital more than 7 days? _______ ____Had seizures? _________________________ Was given medications?_____________ If yes the name of medications: __________________ * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 8 INFANT HEALTH AND TEMPERAMENT DURING THE FIRST 12 MONTHS, WAS THE CHILD… Difficult to feed? ______________________ Difficult to get to sleep? ______________________ Colicky? ____________________________ Difficult to put on a schedule? _________________ Alert? ______________________________ Cheerful? _________________________________ Affectionate? ________________________ Sociable? _________________________________ Easy to comfort? _____________________ Difficult to keep busy? _______________________ Overactive, in constant motion?__________ Very stubborn, very challenging? ______________ AT WHAT AGE DID THE CHILD…? Sit up without help ____________________ Begin crawling _____________________________ Walk alone without assistance ____________________________________________________ Start using single words (e.g. mama, dada) _________________________________________ Start putting 2+ words together ___________________________________________________ Accomplish bowel training, day and night ___________________________________________ Accomplish bladder training, day and night __________________________________________ IF YOU ANSWER YES TO ANY OF THE QUESTIONS BELOW, PLEASE ALSO PUT HOW THEY ARE RELATED TO THE PATIENT. IS THERE ANY BIOLOGICAL FAMILY HISTORY OF…? ADHD? ______________________________________________________________________ Alcoholism? __________________________________________________________________ Arthritis? ____________________________________________________________________ Asthma? ____________________________________________________________________ Allergies? ____________________________________________________________________ Autism? _____________________________________________________________________ Bleeding problems or blood disorders? ____________________________________________ Cancer of any kind? ____________________________________________________________ Cardiovascular? ______________________________________________________________ Diabetes? ___________________________________________________________________ Epilepsy? ___________________________________________________________________ Gastrointestinal? ______________________________________________________________ Glaucoma?___________________________________________________________________ Gout? ______________________________________________________________________ Growth Defects? ______________________________________________________________ Hyperlipidemia? ______________________________________________________________ Hypertension? ________________________________________________________________ * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 9 Heart Disease? _______________________________________________________________ Mental Illness of any kind? ______________________________________________________ Migraines or headaches? ________________________________________________________ Osteoporosis? ________________________________________________________________ Speech Delays? ______________________________________________________________ Stroke?______________________________________________________________________ Tuberculosis? ________________________________________________________________ Thyroid problems? _____________________________________________________________ Other? ______________________________________________________________________ OTHER Has the patient had any surgeries? ________________________________________________ Is the patient currently taking any medications? ______________________________________ Does the patient have any allergies to medications or foods? ____________________________ SAFETY PLEASE CIRCLE ONE Do you feel safe in your home? No Yes Exposure to AIDS: No Yes Excessive exposure at home or work to (circle): Fumes Guns in home: No dust Yes solvents airborne Seat Belt used: No Yes noise temp Have Smoke Detector: No Yes Thank you so much for taking the time to help us understand your concerns regarding your child. Dr. Annelise Spees, M.D., FAAP Doctor’s Medical Group of Colorado Springs 3210 North Academy Blvd., Suite 3 Colorado Springs, CO 80917 Phone: 719-531-0409 Fax: 719-531-0410 * Copyright 2011 Annelise Spees, MD, FAAP for Developmental and Behavioral Pediatrics Version 4/18/11 10
