Down Syndrome Program Intake Form

(To be completed at first visit only)

Child’s Full Name: ______
Date of Birth:______Gender: Male Female
Parent/Legal Guardian Name:______
Home Phone:______Work/Cell Phone:______
Primary Care Physician:______
Please list names of any other Medical Specialists that this child is currently seeing at Riley or elsewhere:
1.______/ 3.______
2.______/ 4.______

Maternal Health and Birth History

1. Was the child? Premature Full -Term Late
2. Length of Pregnancy:______weeks
3. Birth Weight: ______
4. How many weeks was baby in the hospital after birth? ______
5. Location of Delivery: HospitalorBirth Center______Home
Other:______
6. Delivery Method: Vaginal C-Section Breech Forceps Other:______
7. Did the mother have a difficult labor? Yes No______
8. Did the infant experience any of the following problems at birth? Bruising Jaundice Difficulty feeding
Stuck in birth canal Cord around neck Breathing Problems Other:______
______
9. Mother’s Condition: # Pregnancies______# Live Births______#Miscarriages______
10. Mother’s Age: ______11. Father’s Age:______
12. Mother’s Health Conditions During Pregnancy (check all that apply): Hypertension Diabetes Toxemia
Vaginal Bleeding Thyroid Problems Premature Labor Vomiting Recurrent Infections STD HIV
Cigarettes (# of packs per day:______) Alcohol (# of drinks per week:______) Drug Exposure Preeclampsia
Other:______
13. Stresses During Pregnancy (physical and/or emotional):______
14. Please list any medications taken by mother during the pregnancy:
Prescription:______
Over the Counter, Vitamins, or Nutritional Supplements:______

Reviewed by: ______Date: ______

Down Syndrome Program

History of Present Illness

Person Completing this Form:

Relationship to Patient: Mother Father Grandparent

Foster Parent Legal Guardian Other:

Contact # Alternate Contact #___

Primary Care Physician:___

Place Patient Label Here

Name:______

Hosp#:______

DOB:______

Visit Date:______

This Section for Office Use Only

Gestation: ______Birth Weight: ______

What are your main concerns today?

Clinician Notes
For Office Use Only
HPI: EPF: 1 – 3, D: 4, C: 4+
Location, Quality, Severity, Duration, Timing, Context, Modifying facts, Other signs & symptoms
Chief Complaint:______
Kcal/kg/day:
CC/kg/day:

Specific Concerns (check all that apply)?

Large Muscle Skills – head control, sitting, moving

Small Muscle Skills – use of hands, holding objects

Language Skills

Social Skills – looking at you, smiling, playing with others

Behavior Issues

Diet/Nutrition/Feeding

Learning or Thinking Skills

Growth

How long have you had these concerns? ______

Onset of problem was: At Birth Sudden Gradual

How severe are your child’s problems?

Mild Moderate Severe

Would you like to talk to a Social Worker today? Yes No

Diet & Nutrition

1. How does your child feed? By Mouth NG G-tube GJ NJ

2. Name of Formula/Milk ______

3. How often does your child feed? ______

4. How much formula/milk at each feeding? ______

5. Does your child drink anything else? ______

6. What solids does your child eat? Baby foods Table foods

7. Does your child? Choke/Gag Cough Refuse Feedings

8. If your child is over 1 year of age:

Does he/she have problems chewing? Yes No

Does he/she eat: Fruits Vegetables Meat Dairy

9. Does your child spit up or vomit? Almost Never Often Every Meal

10. Does your child have stool problems? Constipation Diarrhea

Development

Can your child?

Roll / Use Fork/Spoon / Speak in 2-3 Word Sentences
Sit / Scribble / Smile
Crawl / Understand “No” / Laugh
Stand / Babble / Play with Children
Walk / Say Single Words / Follows Commands
Run / Point to Objects / Make Eye Contact
Reach for Objects / Put 2 Words Together / Turn to His/Her Name
Behavior
What are your concerns? ______

A Rev. 5/22/09

Clinician Notes
For Office Use Only

Is your child currently receiving any of the following services?

Occupational Therapy / Physical Therapy
Developmental Therapy / Special Education
Speech Therapy / First Steps
Nutrition / Behavioral counseling

Is your child presently in any type of school?______

______

______

Medications – Please complete medication sheet

ALLERGIES Does your child have any drug allergies? Yes No

If yes, please explain: ______

Are your child’s immunizations up to date? Yes No Unsure

D Rev. 11/16/09

Synagis Influenza

Review of Systems

Please review each item as it relates to your child’s health.

ConstitutionalNegative / CardiovascularNegative
Problems sleeping / Heart problems
Anemia / Sweating or tires easily with feeds
Other______/ Other______
NeurologicalNegative / Gastrointestinal Negative
Seizures or staring spells / Vomiting
Balance problems / Diarrhea, or constipation
Other______/ Other______
EyesNegative / Urinary and Bladder System Negative
Vision loss or concerns / History of bladder or kidney infections
Eyes crossing or lazy eye / Problems with toilet training
Tearing or eye discharge / Musculoskeletal Negative
Has your child seen an eye doctor?
No Yes If Yes, when?______/ Muscle weakness
Tightness or stiffnessin joints
Other______/ Other______
Ears/Nose/ThroatNegative / Skin Negative
Hearing loss or concerns / Eczema or rash
Earache or discharge / G tube site or NG tube irritation
Ear tubes? No Yes / Other______
If Yes, when?______/ Endocrine Negative
Tonsils and adenoids removed? No Yes / Thyroid problems
If Yes, when?______/ Other______
When was your child’s last hearing test?______/ Safety/Other
Other______/
  • How does your child travel in a car?

RespiratoryNegative / Forward Facing Car Seat Rear Facing Car Seat
Wheezing / Booster Seat  Seat Belt
Snoring /
  • How does your child sleep (Infants Only)?

Noisy breathing with sleep / On Back On stomach On side Crib Bed
Restless sleep /
  • Yes No Are there any smokers living in your home?

Unusual sleep positions (neck arched back, sitting up) /
  • What year was your home built? ______

Other______/
  • Yes No Do you have concerns about safety in your home?

ALL OTHERS NEGATIVE

Reviewed by: ______Date: ______

D Rev. 11/16/09

Down Syndrome Program

Past Medical, Family, Social History

First Visit – Please fill out completely

Repeat Visit – Indicate ONLY changes since your last visit

Past Medical History No Changes Since Last Visit dated ______
Please check all that apply
Illnesses: / Past Surgeries:
 Seizure Disorder /  Ear PE Tubes /  G Tube
 Asthma /  Tonsils Removed /  Nissen
 Pneumonia /  Adenoids Removed /  Heart Repair
 Other Illnesses/Medical Conditions:______
______/  Other: ______
______
Other Hospitalizations: ______
______
Injuries/Fractures: ______
Procedures and Tests (such as MRI, chromosomes):______
Social History No changes since last visit dated ______
Patients Parents are: Married Divorced Separated Other:______
Child Lives With:Mother Father Foster Parents Other______# of others living in home:______
# of Siblings:______Ages and health of Siblings:______
Mother Employed? Yes No If yes, Occupation:______
Father Employed? Yes No If yes, Occupation:______
Is the family currently receiving any of the following services? WIC SSI CSHSC Medicaid Waiver Medicaid Disability
Childcare Provided by: Parents Relatives HomeDaycare Babysitter/Nanny Daycare Center
Family Medical History No Changes Since Last Visit dated ______
Please indicate any history of the following illnesses among the patients immediate family by checking the appropriate box.
Immediate family consists of parents, siblings, and grandparents only.
 ADD/ADHD /  Diabetes /  Kidney Disease /  Cerebral Palsy
 Alcohol/Drug Abuse /  Genetic Conditions /  Learning Problems /  Seizures/Epilepsy
 Allergies/Asthma /  Growth Problems /  Liver Disease /  Mental Retardation
 Autism/Asperger/PDD /  Heart Disease /  Mental Illness /  Neurological Disorder
 Cancer /  High Blood Pressure /  Thyroid Problems
Other (please list): ______

Reviewed by: ______Date: ______

My child is under age 3

All kids ages 3-19:

If your child is in school:

  1. What school does he/she attend?
  2. How many hours per day are spent in special ed or resource room?
  3. How many hours per day are spent in mainstream classroom?
  4. What skills is your child working on?
  1. Does your child receive private therapies in addition to school based therapies?
  1. Does your child participate in any activities outside of school (e.g. sports, Special Olympics, scouting, Best Buddies, Sunday school)?
  1. What are your child’s responsibilities at home (self-care, chores, etc.)?

Teens only:

  1. Has your teen had any vocational work experiences?
  1. Does your teen spend time with friends outside of school?
  1. Have you and your teen started discussing plans for the future (educational, vocational, living arrangements)?
  1. Do you need more information about legal and financial transition to adulthood issues (guardianship, financial planning, etc.)?
  1. Any questions/concerns about puberty or menstruation?
  1. Any questions/concerns about sexuality or sexual behavior?

D Rev. 11/16/09