Division of Developmental and Behavioral Pediatrics

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For physician notes
Division of Developmental and Behavioral Pediatrics
North Shore-LIJ Health System / Children’s Health Network
Parent Questionnaire
The information you provide will help us evaluate your child. Please answer all questions to the
best of your ability. If you don’t have particular information, write “don’t know.” Be sure to
complete both sides of each page. If you need more space for any question, use the last page of
this packet.
Child’s Name _____________________________ Sex ______ Birthdate ___________________
Address ________________________________________________________________________
(Number and street)
(City/State)
(Zip)
Mother’s Name
Father’s Name
Street Address
Street Address
City, State Zip
City, State Zip
Home Phone
Home Phone
Work Phone
Work Phone
Alternate Phone
Alternate Phone
Referring Pediatrician
Phone
Address
Reason for Consultation
In a few words tell us what questions you or your pediatrician would like us to try to answer for
you. If you need more room feel free to use the additional space on the last page to tell us more
about your child and the concerns you may have:
School History
Name of child’s current school
City/Town
Is this school:
Type of program:
Public
Private or Parochial
Present grade in school
Regular classroom
Self-contained special education classroom
Early Intervention (under age 3; center-based or in home)
Other:
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Child’s name ________________________________ (page 2)
Check additional services child currently receives (In school or privately):
Inclusion teacher
Resource room
Remedial reading or math
1:1 aide
Speech/language therapy
Physical therapy
Occupational therapy
Counseling in school
Applied behavioral analysis (ABA)
Private psychotherapy
Social skills group
■ Educational tutoring
Other
List other schools/programs your child has attended, including early intervention services and
nursery and preschools.
City or Town
School/Program
Grades attended
1.
2.
3.
4.
Has your child ever repeated a grade?
Yes
Has your child been previously evaluated?
Type of Evaluation
No If yes, which?
Yes
No (If yes, provide details below)
Year (or Age)
Evaluator (name of program or person)
Psychological
Educational
Speech/Language
Hearing
Ophthalmology (vision)
Physical or occupational therapy
Auditory Processing
Psychiatry
Neurology
Other (e.g. allergy, orthopedics)
Does your child have a current IEP (Individualized Education Plan) for school?
If yes, what is your child’s classification for educational purposes?
Do you help you child with homework?
Observations?
Yes
No
Yes
No
Child’s name ________________________________ (page 3)
What are your educational goals for your child?
Are you satisfied with the way the school has met your child’s needs? What do you think they
could have done or should do differently?
Medical Information
Was this child adopted?
No
Yes
At what age?
Please list all of birth mother’s pregnancies (List name of child, or indicate if miscarriage or
termination of pregnancy. INCLUDE THIS CHILD:
Name
Sex
Year
Birthweight
Length of Pregnancy (Weeks)
1.
2.
3.
4.
5.
During the pregnancy with this child did mother:
Yes
Have a chronic illness?
Take any medications?
Drink alcoholic beverages?
Use drugs?
Spill sugar in urine or have diabetes?
Smoke?
Have a severe accident?
Have any infections or rashes?
Have high blood pressure?
Have excessive weight gain?
Have bleeding or threatened miscarriage?
Have amniocentesis / other prenatal testing?
Require hospitalization?
Have any other medical problems?
■
No
Specify:
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Child’s name ________________________________ (page 4)
Birth History:
Name of hospital where child was born
City
Was this a multiple birth (twins, etc.)? If so, describe
Did the labor start:
Spontaneously
Induced
No labor
Baby was delivered:
Head first
Feet first
By cesarean section
Did the baby breathe and cry right away?
Yes
No
Comments about any difficulties with the delivery
While the baby stayed in the hospital did he/she:
Yes
No
Comments
No
Comments
Have a heart murmur?
Have convulsions or seizures?
Have any breathing problems?
Have any feeding problems?
Require treatment for jaundice?
Receive a blood transfusion?
Have any infections?
Require surgery?
Have any other problems?
How many days did the baby stay in the hospital?
As an infant did the baby:
Yes
Have any problems feeding?
Have colic or cry excessively?
Fail to gain weight or grow normally?
Seem limp or weak?
Seem stiff or have tight muscles?
Experience sleep problems?
Have a normal activity level?
Have tremors or convulsions?
Drool after 2 1/2 years of age?
Child’s name ________________________________ (page 5)
Developmental Milestones:
At what age did your child:
Smile at you
Babble
Roll over
Use single words meaningfully
Sit alone
Point to show you things
Crawl
Put two words together
Walk alone
Start to feed him/herself
Pedal a tricycle
Start to dress him/herself
Use a bicycle (no training wheels)
Start to toilet train him/herself
Tie shoes
Are there any skills which your child mastered that he/she subsequently lost? Yes
No
Comment
Was child’s development/behavior much different from that of brothers/sisters? Yes
Comment
Medical History — Hospitalizations:
Age
Reason
Age
Reason
Age
Reason
Has your child had any of the following tests?
■
EEG
Age when last done
Normal
Abnormal
■
CT scan or MRI Age when last done
Normal
Abnormal
■
Genetic testing
Age when last done
Normal
Abnormal
■
Thyroid tests
Age when last done
Normal
Abnormal
■
Other
Age when last done
Normal
Abnormal
Present Medications:
Name
1.
2.
3.
4.
Previous Medications:
Name
1.
2.
3.
4.
Dose/Times
Ages when taken
No
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Child’s name ________________________________ (page 6)
Are your child’s immunizations up-to-date? Yes
No
Medical History (Review of Systems):
Does your child have or has your child had any, of the following?
No
Details/Comments
Yes
Headaches
Trouble seeing
Trouble hearing
Frequent ear infections
Dizziness or fainting spells
Meningitis or encephalitis
Head injury
Seizures or convulsions
Tics or nervous habits
Sleep problems
Frequent pneumonia
Asthma
Heart defect
Urine or kidney infections
Trouble chewing / swallowing
Frequent nausea or vomiting
Frequent diarrhea
Constipation
Frequent stomach aches
Overweight
Underweight
Excessively dry skin
Hair loss
Bruises easily
Broken bones
Any surgical operations
Environmental allergies
Allergies to medication
Serious infections
Lead poisoning
Family History:
Under parents, list names of children in order of birth:
Year of
Highest grade
Birth
completed
Occupation
Father
Mother
1.
2.
3.
4.
5.
School problems?
Child’s name ________________________________ (page 7)
Yes
No
Relationship to Child
A birth defect
Speech or language delay
Hearing loss or deafness
Vision impairment or blindness
Cerebral palsy
Muscle weakness
Epilepsy; seizures
Learning problems
Mental retardation
Developmental delay
Hyperactivity or ADHD
Autism or PDD
Anxiety or nervousness
Motor or vocal tics
Tourette Syndrome
Obsessive/compulsive disorder
Depression or bipolar disorder
Excessive alcohol or drug use
Conduct disorder
Other psychiatric problems
Difficulty with the law
Social/Environment:
Who lives at home?
Are parents living together?
Yes
No If not, please explain (Separated, divorced, one
parent deceased, e.g.)
What languages are spoken at home?
Are there significant marital conflicts?
Yes
No
N/A
Do parents agree on how to discipline child?
Yes
No
N/A
Are there significant conflicts between child and parents
Yes
No
N/A
Is child easy to discipline?
Yes
No
N/A
Are there significant conflicts between child and his/her siblings?
Yes
No
N/A
Does child have difficulty getting along with other children?
Yes
No
Does child have difficulty getting along with other adults?
Yes
No
What is your child good at or does he/she enjoy doing? What are his/her positive attributes?
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Child’s name ________________________________ (page 8)
Additional information you want to provide about your child and reason for this consultation:
If available, attach photo of child:
Name of Person Completing this Form
Your relationship to child
Today’s Date
PLEASE CHECK TO SEE THAT YOU’VE COMPLETED BOTH SIDES OF EACH PAGE,
THANK YOU! Include photocopies of previous test reports or other materials that you would like
us to review.
Reviewed by (Developmental Pediatrician’s Signature)