Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download 1 Behavioral and Developmental Pediatrics Capital Area Pediatrics
Document related concepts
Transcript
Behavioral and Developmental Pediatrics Capital Area Pediatrics Patient Referral for Dr Panitz For children 0- 10 years of age 1. To schedule your initial appointments, leave a message for Linda Pesce (703-860-4200 ext 9) and she will return your call within 3-5 business days. Linda will put you on a wait list and your appointment will be scheduled within 3-5 months. 2. You will schedule two initial appointments: *First one hour appointment for parents only *Second 90-minute appointment for child assessment and parent discussion 3. A written summary will be sent to your primary clinician and to you when the visit is completed. 4. Some assessments will be enhanced by a school observation. This can be discussed at the first appointment and is not an insurance reimbursable service. The family will need to accept full responsibility for the $250 charge for this service. 5. Please bring any additional documentation to the first appointment that might be helpful: IEPs, school assessment, progress reports, growth data, outside evaluations, etc. 6. Please complete this questionnaire and bring it to your first appointment. 1 Herndon Office 12950 Highland Crossing Drive, Suite H Herndon, VA 20171 703-860-4200 703-860-1528 (fax) FROM TYSONS, FALLS CHURCH, ARLINGTON AND AREAS EAST Take Dulles Toll Road West towards Reston. Get off at Fairfax County Parkway exit and turn Left (South) after tollbooth. Go over Toll Road and go to 1st stoplight, Sunrise Valley Drive. Turn Right. Go to 4th stoplight, Woodland Point Avenue. Turn Right. Make immediate Left into shopping center, Highland Crossing Drive. FROM ASHBURN, LESSBURG AREA Take Dulles Toll Road East towards Reston. Get off at Centreville Road exit and turn Right at stoplight. Go to stoplight at Sunrise Valley Drive and turn Left. You will pass McNair Farms Shopping Center on Right (Shoppers). Go to 2nd stoplight, Woodland Pointe Avenue. Turn Left and make immediate Left into shopping center, Highland Crossing Drive. FROM ELDEN STREET/BARON CAMERON STREET, COUNTRYSIDE/STERLING, GREAT FALLS. Take Fairfax County Parkway South from Elden Street. Go over Toll Road to next stoplight Sunrise Valley Drive. Turn Right. Go to 4th stoplight at Woodland Pointe Avenue. Turn Right and make immediate Left into shopping center, Highland Crossing Drive. FROM VIENNA, FOX MILL ROAD Take Foxmill Road West from Reston Parkway to Fairfax County Parkway. Turn Right. Go to 1st stoplight at Sunrise Valley Drive. Turn Left. Go to 4th stoplight at Woodland Pointe Avenue. Turn Right and make immediate left into shopping center at Highland Crossing Drive. FROM ROUTE 50, FAIRFAX, BURKE, CENTREVILLE, MANASSAS AREAS Take Fairfax County Parkway North towards Reston. Go to stoplight at Sunrise Valley Drive (one stoplight beyond Foxmill Road). Turn Left. Go to 4th stoplight at Woodland Pointe Avenue. Turn Right and make immediate Left into shopping center at Highland Crossing Drive. FROM PARKING LOT (HIGHLAND CROSSING DRIVE) Take elevators outside right-hand entrance of Harris Teeter or from garage (entrance behind Chevy Chase Bank). Take green elevators in center of garage up to L2 (2nd Floor), Suite H. 2 Behavioral and Developmental Pediatrics New Patient Questionnaire PLEASE COMPLETE AND BRING TO YOUR FIRST APPOINTMENT FOR PARENTS ONLY. Feel free to use the reverse side for additional comments. Date: _________________________ Appointment date: _____________ Child’s Name: _______________________________________________________ Date of Birth: ___________________ Age of Child: __________________ Address: ___________________________________________________________ Contact Numbers: Home: ___________ Cell: ___________ Work: ____________ Email Address: ______________________________________________________ Person completing form: ___________________ Relationship to child: _____ Who recommended this appointment? ___________________________________ Pediatrician: ________________________________________________________ Primary language spoken at home: ______________________________________ What concerns do you have today about your child? What are your goals for this evaluation? How long have you had these concerns? Was there anything that brought these concerns on? What have you tried that has worked? What have you tried that has not worked? 3 In what contexts are these problems an issue? __Home __school __other: Please describe 1. Please check all that are relevant. You are concerned about your child’s: ___Behavior ___Development ___Ability to learn ___Symptoms that may be Autism ___Having trouble in school ___Attention/hyperactivity problems ___Other, please specify: _________________________ 5. Child’s challenging behaviors: Check all that apply and describe: __Toileting: diarrhea; yes ___ no ___; constipation; yes ___ no ___ __Eating: __Tantrums: __Social skills: 6.Does your child have sleep challenges? Yes No __ __ Wakes during night __ __ Trouble getting to sleep __ __ Sleeps independently __ __ Snore? __ __ Early riser __ __ Seems sleepy, falls asleep during the day 7. Your child’s strengths: 4 Child’s Name: _________________________________________ Who lives in the child’s home? Name Age Relationship 1. 2. 3. 4. 5. 6. Parents ___married ___never married ___divorced ___separated ___living together ___living separately Father’s highest level of education: _______________ Occupation: _____________ Mother’s highest level of education: _______________Occupation: _____________ Language(s) spoken at home: primary_____________ other: __________________ Are you the biologic parent(s) of this child? history: □Yes □No if not, please share Other family members regularly involved with the child: Other adults regularly involved with the child: Does your child have a babysitter? In your home? In daycare? In-home care? What are their observations/concerns? 5 Child’s Name: _________________________________________ MEDICAL HISTORY Which number pregnancy for you was this? ___________________________ Prior pregnancies? __Terminations? __Miscarriages? __Live births? Was baby born early? __Yes __No If so, how early? __________________ Birth weight: __________________ __c/section: reason for: APGAR scores: ___________ __vaginal birth Were there any problems with the pregnancy? Check all that are relevant: __Hospitalizations ___History of Infertility __Bleeding __Medications describe: __Alcohol use __Cigarette smoking __Street drug use __History of miscarriage or infant death __Was the child brought to you right away or kept in the special care nursery? Home from hospital after how many days? _______________________________ Problems in the first month of life? ______________________________________ Describe your child as an infant: Breast or bottle fed? ______For how long? ______ Problems? _______________Was s/he irritable? _____Difficult to arouse? _______ Had poor weight gain? ___________________ Past medical concerns? Does your child get sick frequently? Has your child ever had ___heart disease ___irregular heart rate ___fainting? Does your child’s development change significantly with an illness? Surgery? Hospitalizations? 6 Child’s Name: _________________________________________ Present medical conditions: Medications ___________________________________________________ Nutritional or biomedical treatments ________________________________ _____________________________________________________________ Allergies _____________________________________________________ Food intolerances ______________________________________________ Specialists your child has seen: EARLY DEVELOPMENTAL HISTORY Please list age at which the following milestone was first seen: First smile __________________________ Babbled, repeated consonant sounds like “mama” or “baba” _______________ Weaned off breast/bottle? __________________________________________ Sat alone? ______________________________________________________ Walked independently _____________________________________________ Spoke first meaningful words? _______________________________________ Put words together ________________________________________________ Spoke 2-3 word sentences __________________________________________ Fed self with spoon/fork ____________________________________________ Able to dress self _________________________________________________ Able to separate __________________________________________________ Potty trained _____________________________________________________ Slept through the night _____________________________________________ 7 Child’s Name: _________________________________________ FAMILY HISTORY Have any immediate family members had the following, check all that apply and indicate whom: Check If Applicable Family member Hyperactivity Trouble learning in school Delayed language Delayed/awkward social skills Autism Seizures Behavior problems Depression Drinking or drug abuse Other mental illness Heart Disease/cardiac death Irregular heart rhythm Fainting spells Chronic medical issues Cancer Has this child been exposed to any stressful experiences such as bullying, marital problems, violence, inappropriate touch or abuse, death of a loved one? Please describe: 8 Child’s Name: _________________________________________ PLEASE CHECK ALL THAT APPLY BEHAVIORAL TRAITS Rarely Occasionally Often Unable to Comment Bad temper Whiney Fearful Sadness Difficult to comfort Difficulty with frustration Difficulty with transitions Difficulty with new people Frequently ill Frequently tired Concerned about neatness or cleanliness Resists cuddling Resists getting messy, putting on clothing, or touching some textures Startles easily with sounds Becomes overexcited in busy settings Puts objects in mouth Steals Lies Bullies Mean Gets in trouble Fearless Has few friends Seems sad, unhappy, has anxiety Has difficulty with separation Is not liked by other children Seems unaware of other children Does not play with other children Has trouble with changes in routine Asks for help too frequently Acts as if on the go Moods are intense Easily distractible Loses focus easily Unpredictable schoolwork Daydreams Craves excitement Have trouble getting his attention 9 Child’s Name: _________________________________________ CHECK ALL THAT APPLY Rarely occasionally often cannot comment Asks questions Points to things Takes turns speaking Expresses emotion Uses attention getting words (“hey” or “look”) Uses adjectives Engages in pretend play Makes dialogue and becomes character in play Makes eye contact Responds to being called Responds when you try to get his attention: “look” Tells a story Can follow 1 or 2 step instructions Uses words to ask for things Imitates sounds Answers questions Asks for help 10 Child’s Name: _________________________________________ Does your child exhibit any repetitive or self-stimulating behaviors such as spinning, rocking, lining up toys, or head- banging? Additional comments you would like to share: Do I have your permission to speak with and possibly visit your child’s school? Contact person: Name of School: Email: ________________________ Telephone: _______________________ __Yes please contact the school. ___No, please do not contact the school. __________________________________________Signature __________date Do I have your permission to speak with another professional involved with your child? Contact professional: Professional role: Email: ________________________ Telephone: _______________________ __________________________________________Signature __________date I look forward to meeting you, Polly Panitz, M.D. Please bring additional relevant paperwork to your appointment, i.e., medical records, laboratory results, etc. 11 Developmental and Behavioral Service Financial Responsibility Notice The developmental and behavioral services that are provided by Dr. Polly Panitz are highly specialized and have limited availability in the Washington metropolitan area. Capital Area Pediatrics, Inc. (CAP) is happy that we can provide her services to our patients. Dr. Panitz is credentialed with those insurance companies with which CAP participates. Although the majority of CAP patients receive reimbursement for Dr Panitz’s services, this does not guarantee that her services will be a covered benefit under your child’s health plan. Coverage is based on diagnosis and services provided, and this will be determined after a claim is received and processed by the patient’s insurance plan. Due to the specialized nature of these services, the patient’s diagnosis is often very specific and CAP will not adjust the diagnosis to meet the criteria of the health plans benefit package. If you have concerns about why specific diagnoses are not covered, please address this question to a representative from your insurance company. We have listed the likely charges for each visit, but cannot determine the diagnosis prior to your appointment. It will be your responsibility to check with your insurance provider prior to each visit to be certain they will cover each visit. Initial Visit with Parents Only; 99245 Consultation – 1 hour with parents $ 400.00 Second Visit with Parents and Child: 99215 Office Visit $207.00 96116 Neurobehavioral Testing, total time face to face with the patient administering test and time interpreting test reports and preparing reports. Typically 2 hours will be charged. $203.00 Charge per hour School Visit SCHOOL School Visit (Not covered by insurance.) $250.00 Payment for this service is required in advance to school visit. Follow Up Visits 99215 Office Visit $207.00 99354 Prolong service $137.00 96110 Developmental Screening with interpretation and report. $21.00 per test Not to exceed 3 tests. (If indicated) I have read the information listed above and understand that due to the specialized nature of the services provided by Dr. Panitz, I will be responsible for services not covered by my insurance carrier, including but not limited to co-‐pays, deductibles and non-‐covered services. I also agree to a cancellation fee of $50.00 if 48 hours notice is not provided. Patient’s Name: _____________________________________________ DOB: ____________________________ Name of Parent or Guardian: ____________________________________________________________________ Signature of Parent or _______________________ Guardian: _____________________________________ Date:
