New Patient Information

New Patient Information

Patient Name:______Date:______

Date of Birth:______Age:______Sex:______

Reason for visit: ______

Referred by (please include phone number): ______

Primary Physician Name:______Phone Number: ______

Other Physicians:

Neurology: Yes No Last Visit:______

Orthopedics: Yes No Last Visit:______

Ophthalmology (Eye): Yes No Last Visit:______

GI: Yes No Last Visit:______

Pulmonology: Yes No Last Visit:______

Psychologist/Psychiatrist:: Yes No Last Visit:______

Dentist: Yes No Last Visit:______

Other: Yes No Specialty/Last Visit:______

If the patient is a female over the age of 18, do they have a OB/Gyn Physician?

Yes No Last Visit:______

MEDICATIONS:(Please list all medications including dosage that patient is currently taking-if applicable please attach the patients medication sheet):

______

______
______

______

BIRTH/DEVELOPMENTAL HISTORY:

Birth Weight:______Type of Delivery(Vaginal, C-Section, etc.):______

Premature? If so, how many weeks gestation:______

Any complications during pregnancy, delivery or immediately post delivery? If so, what: ______

______

Is patient product of Multiple birth or infertility treatments?______

Child sat at:______Child walked at:______Child spoke at:______

SURGICAL/BOTOX HISTORY:(Please list all surgical/botox procedures the patient has undergone including type and date. If additional space needed, please attach information):______

______

______

______

______

______

PAST MEDICAL AND FAMILY HISTORY:

Has the patient or a relative had treatment for, or problems with the following (if yes, please describe in comments):

PATIENT / RELATIVE
(Pls. state which relative) / COMMENTS:
Eyes, ears, nose, mouth, throat
Lungs (asthma, breathing problems)
Heart, blood vessels, high blood pressure
Stomach, intestines, liver, pancreas, glands
Bladder, kidneys, urinary system
Bones, joints, tendons, ligaments, muscles
Skin (eczema, psoriasis, infections)
Endocrine (diabetes, growth hormone, thyroid)
Blood disorders, Lymphatic disorders, Cancer
Neurologic (spasticity, nerve problems, CP)
Psychiatric disorder, attention defecit problems
Immune system problems, infections

OTHER ISSUES/CONCERNS: Does the patient have any other issues/impairments including:

Intellectual/School: ______

Visual: ______

Hearing: ______

Speech: ______

Respiratory: ______

Cardiac: ______

Gastrointestinal/Feeding: ______

Bowel/Bladder:______

Sleep:______

Skin:______

Other: ______

SOCIAL HISTORY:

Legal Guardian of Child:Mom DadOther:______

Grade in school:______Name of School:______

Recreation/Sports:______

ADAPTIVE EQUIPMENT:

Does the patient use any adaptive equipment including:

Equipment Problems/Questions/Concerns:

Power wheelchair Yes

Manual wheelchair Yes

Stander Yes

Gait Trainer Yes

Bath/shower equipment Yes

Lift/transfer equipment Yes

Stroller Yes

Arm Braces/Splints Yes

Leg Braces/Splints/AFO’s Yes

Back brace Yes

Car seat Yes

Hospital bed Yes

Feeding/Support Chair Yes

Commode Equipment Yes

Other:______Yes

REHABILITATION SERVICES:

Does the patient currently receive any of the following services (If yes, please state location and frequency):

Physical Therapy None School MTU Childrens Hospital Other

Location and Frequency:______

Occupation Therapy None School MTU Childrens Hospital Other

Location and Frequency:______

Speech TherapyNone School MTU Childrens Hospital Other
Location and Frequency:______

If you wish to make any further comments please do so here: ______

______

______
______

______

We would like to thank you in advance for completing this form.

Rev: Sept 2016