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Patient_Questionnaire

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					                                             Children’s Specialized Hospital
                                                  1(888) CHILDREN

                                            PATIENT QUESTIONNAIRE
As you go through this form, if you feel a particular section is not necessary for the purpose of serving your child, do
not complete that section. Thank You.

Section 1- IDENTIFYING INFORMATION

Child’s Name ______________________________________ Birthday ____/____/____                  Sex _____________

Address ___________________________________________________________________________________

__________________________________________________________________________________________

Home Phone _________________________________ Referred by __________________________________

Diagnosis (if known) ________________________________________________________________________

Reason for visit ____________________________________________________________________________

Current School Placement

Name ____________________________________________________________________________________

Address __________________________________________________________________________________

Classification _______________________________________ Last CST Eval ________________________

Therapies now received:
( ) PT _________________            Frequency __________________________

( ) OT _________________            Frequency __________________________

( ) Speech ______________           Frequency __________________________

( ) Psych _______________           Frequency __________________________

Current Physicians                                                Addresses

Pediatrician ___________________________________/______________________________________________

Neurologist ___________________________________/______________________________________________

Orthopedist ___________________________________/______________________________________________

Other ________________________________________/______________________________________________

Has your child registered with NJ Special Health Service?     Yes _____       No _____

When? _________________             Name of Case Manager ____________________________________________




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Medications

Name                                   Dose                                    Date started




Allergies

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________


Section 2- FAMILY INFORMATION

Mother _________________________________________________________ Birthdate ________________________

Father __________________________________________________________ Birthdate _______________________

Siblings and other household members:
Name                             Relation to child                    Age                       Problems

________________________           ______________________             ______________            ________________

________________________           ______________________             ______________            ________________

________________________           ______________________             ______________            ________________

Has anyone in the family (mother’s or father’s side) had significant medical or emotional illness? _________________

Details _________________________________________________________________________________________

________________________________________________________________________________________________




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Section 3- PREGNANCY HISTORY

Times pregnant ________________ Miscarriages ________________ Abortions _______________________

Health during pregnancy:

Illnesses ______________________________________ Accidents _________________________________________

Medications/Vitamins taken ________________________________________________________________________

Drugs/Alcohol/Smoking ___________________________________________________________________________

Any other difficulties ______________________________________________________________________________

Length of pregnancy (full-term or premature) ___________________________ weeks or months

Labor & Delivery

Hospital _________________________________ Length of labor _____________ Medications given ____________

Problems _______________________________________________________________________________________

Delivery:
Normal __________          Induced __________      C-Section __________   Forceps __________

Problems during delivery _____________________________________________________________

Birth weight __________ Length __________          Apgars __________

Neonatal Care:
Regular Nursery _________________________          ICN __________________________

Jaundice _________________________       Did the baby need lights?

Did the baby:     (Yes or No)
Turn blue ___________________
Have difficulty breathing ___________________
Need a respirator __________________________ how long _________________________________
Have seizure _____________________________       meds ____________________________________
Have muscle tremors _____________________________________
Have bleeding in the brain _________________________________
Have difficulty feeding ____________________________________
Have surgery (what kind) __________________________________

Details on any of the above _________________________________________________________________________

________________________________________________________________________________________________


How old was the baby when he/she came home? __________________________________________




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Section 4- MEDICAL/DEVELOPMENTAL HISTORY

Previous evaluations (Please list: dates, type of evaluation, facility, and clinician)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Previous therapy/therapy-treatment (Please list: dates, facility, and type of operation)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Operations/hospitalizations (Please list: dates, facility, and type of operation)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Serious illnesses/injuries/loss of consciousness (Please list dates, type)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Section 5- DEVELOPMENTAL MILESTONES

To the best of your memory, state at what age your child accomplished each of the following. Please check those items
your child had difficulty achieving.
Gross Motor                                 Age/Difficulty
Held head up                         ____________________________
Sat w/o support                      ____________________________
Crawled on the floor                 ____________________________
Stood alone                          ____________________________

Fine Motor
Transferred from hand to hand     ____________________________
Held bottle                       ____________________________
Built blocks                      ____________________________
Used spoon ( ) fork ( ) cup ( )   ____________________________
Did buttons ( ) tied shoes ( )    ____________________________

Speech and Feeding
Smiled                             ____________________________
Babbled                            ____________________________
Played games: peek-a-boo           ____________________________
              patti-cake           ____________________________
              other                ____________________________
Words/phrases                       ____________________________
Simple sentences                   ____________________________
Baby food                          ____________________________
Table food                         ____________________________
Drank from a cup                   ____________________________




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(Development continued)
Pointed to body parts              ____________________________
Recognized colors                  ____________________________
Named colors                       ____________________________
Recognized shapes                  ____________________________
Named shapes                       ____________________________
Recognized numbers                 ____________________________
Recognized letters                 ____________________________

Toilet trained                      ____________________________
Dry at night                        ____________________________


Section 6 – PRESENT DEVELOPMENT

Height ____________                 Weight ____________

Medical problems (ear infections, seizures, allergies, etc) ________________________________________________

Vision: good __________ poor __________             formally tested? yes ____ no ____   glasses? yes ____ no ____

Hearing: good ____________ poor __________ formally tested? yes ____ no ____ when? ___________________

Teeth: good ___________ poor ___________ seen by a dentist? yes ____ no ____ when? ___________________

Feeding difficulties ____________ Sleeping difficulties ____________ Toileting difficulties ____________

Walking pattern: normal __________ abnormal __________

Describe details of any above________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Wears splints/braces: yes _______ no ________ If yes, what kind? _________________________________________

Uses special equipment: ( ) wheelchair ( ) walker ( ) stander ( ) bath chair

Other __________________________________________________________________________________________

Coordination: good __________ fair __________ poor __________

Talking pattern: (examples of speech) _________________________________________________________________
________________________________________________________________________________________________

Behavior/personality- Please check all that apply

Activity level: ( ) quiet ( ) average ( ) overactive ( ) hyper
( ) cooperative                   ( ) self confident
( ) pays attention                ( ) follows directions
( ) understands what is said      ( ) generally happy
( ) frustrates easily             ( ) other ______________________________




                                                            5/6
How does your child interact with:

Brothers and sisters ______________________________________________________________________

Mother _______________________________________             Father __________________________________________

Children his/her age ______________________________________________________________________

Other adults _____________________________________________________________________________

Favorite toys and activities _________________________________________________________________________

_______________________________________________________________________________________________

Dislikes ________________________________________________________________________________________

Fears __________________________________________________________________________________________

How do you discipline your child ____________________________________________________________________

_______________________________________________________________________________________________

What areas of behavior are harder for you to deal with ___________________________________________________

_______________________________________________________________________________________________

Does your child have difficulty separating from you    ( ) yes   ( ) no

Is there anything else you would like us to know about your child? __________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________




____________________________________                  _____________________________        ________________
Signature                                             Relationship to child                Date




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