To Be Completed at First Visit Only

Myelomeningocele 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
3. Was there a prenatal diagnosis made? Yes No / 2. Length of Pregnancy:______weeks
4. Did you meet with specialists prior to birth? Yes No
3. Was there a prenatal repair performed? Yes No If Yes, where:______4. Birth Weight: ______5. How many weeks was baby in the hospital after birth? ______
6. Location of Delivery: Hospitalor Birth Center______Home
Other:______
7. Delivery Method: Vaginal C-Section Breech Forceps Other:______
8. Did the mother have a difficult labor? Yes No______
9. Did the infant experience any of the following problems at birth? Bruising Jaundice Difficulty feeding Infection
Stuck in birth canal Cord around neck Breathing Problems Seizures Birth Defects Brain/Ventricle Bleeding
Other:______
10. Mother’s Condition: # Pregnancies______# Live Births______#Miscarriages______
11. Mother’s Age: ______12. Father’s Age:______
13. 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 before and/or during the pregnancy:Folic Acid Prenatal Vitamins
Prescription:______
Other______:______

Reviewed by: ______Date: ______

Place Patient Label Here

Name:______

Hosp#:______

DOB:______

Visit Date:______

This Section for Office Use Only

Myelomeningocele Program

History of Present Illness

Person Completing this Form:

Relationship to Patient: Mother Father Grandparent

Foster Parent Legal Guardian Other:

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)?

Behavior Issues / Refills/Medications
Diet/Nutrition/Feeding / G-tube
Bowel/Bladder / Shunt
Tether Cord / School
Growth/Development  / Wound/Skin
Equipment

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

Diet & Nutrition

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

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? Purees Table foods

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

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

9. Does your child have textural difficulties with foods? Yes No

Medications – Please complete medication sheet

______

______

ALLERGIES

Does your child have any drug allergies? Yes No

If yes, please explain: ______

Latex Allergy: Yes No Precautions

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

EQUIPMENTIs your child using any of the following?

AFO’s SMO’s UCBL’s KAFO’s HKAFO’s

Twister Cables Walker Forearm Crutches Stander

Wheelchair Gait Trainer Parapodium RGO

Other:______

Clinician Notes
For Office Use Only

SERVICES

1. Is your child currently receiving any of the following services?

Occupational Therapy / Physical Therapy
Speech Therapy / Behavioral Counseling
Developmental Therapy / Hippo Therapy
Aquatic Therapy / Nutritional Therapy

1. Is your child presently in any type of school? Yes No

Classroom Type: ______

School Name:

Grade:

Hours per Day:Days per Week:

3. Is there an IEP? Yes No

4. Has psychoeducational tesing been performed? Yes No

5. Are there difficulties with: ReadingWriting

Math Science Spelling

Other:______

Home Care Agency

1. Is your child currently receiving Home Care Services?

SuppliesNursingDME

Names:

______

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MobilityGrowth and Development

1.Is your child mobile by: 1. Is your child doing any of the following:

Crawl / Drag/Army Crawl  / Reach for Objects / Use Fork/Spoon
Bear Crawl / Scoot / Scribble / Use Single Words
Cruise / Roll / Use Two Words Together / Speak 2-3 Word Sentences
Assistive Devices / Walker / Recite ABC’s / Count
Stander / Forearm Crutches / Recognize Letters/Numbers / Stack Blocks
Manual Wheelchair / Power Wheelchair / CopyCircles/Squares / Write Letters/Numbers
Gait Trainer / RGO / Assist with Dressing / Assist with Personal Care
Independent with Dressing / Independent with Hygiene

Language

1. How does your child let you know what he/she wants?

Words / Eye Gaze / Facial Expressions
Crying / Pointing / Assistive Device

Reviewed by:______Date:______

Myelomeningocele Program

Review of Systems

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

ConstitutionalNegative / Gastrointestinal Negative
 Problems sleeping /  Nausea and/or vomiting
 Anemia /  Diarrhea, or constipation
Significant weight gain/loss / Gastroesophageal reflux
Recent fevers, chills or sweats / Abdominal pain
 Other______/ G-tube/J-tube/GJ-tube
Neurological Negative / Enema/Suppository Use
 Seizures or staring spells / MACE: Amount:______Frequency:______
 Headaches /  Other______
Dizziness/light-headedness / Urinary and Bladder System Negative
Numbness or tingling /  History of bladder or kidney infections
Problems with concentration / Spontaneous void
Irritability / Toilet Trained
 Other______/ Catheterization: How often?______
Eyes Negative / Vesicostomy
 Vision loss or concerns / Monti (Ileovesicostomy)
 Eyes crossing or lazy eye / Mitroffanoff (Appendicovesicostomy)
Nystagmus (eyes bouncing) / Bladder Augmentation
Has your child had a vision test?
 No Yes If Yes, when?______/ Other______
Musculoskeletal Negative
 Other______/ Muscle weakness
Ears/Nose/Throat Negative / Tightness or stiffness in joints
 Hearing loss or concerns / Pain in neck, back, arms, legs
 Earache or discharge / Muscle spasms or cramps
Has your child had a hearing test?
 No Yes If Yes, when?______/ Scoliosis/curvature of spine
Joint pain or swelling
Difficulty swallowing / Broken bones
Frequent or worsening choking/gag reflex / Receives Botox
Drooling / Other______
Change in quality/pitch of voice / Skin  Negative
Does your child see a dentist? /  Eczema or rash
 No Yes If Yes, when?______/  G tube site or NG tube irritation
Other______/ Wounds
 Respiratory Negative / Birthmarks
 Wheezing / Other______
 Snoring or noisy breathing with sleep / Endocrine Negative
Cough /  Thyroid problems
Stridor / Pubertal changes
Tracheostomy / Menses No Yes If Yes, 1st period ______
Cpap/Bipap / Precocious puberty (premature puberty)
Oxygen / Growth hormone
Apnea (Breathing Stops) / Excessive sweating
Reactive Airway/Asthma /  Excessive thirst and urination
 Other______/ Feeling too hot or too cold
 Pulmonologist /  Other______
Cardiovascular Negative / Safety/Other Negative
 Heart problems/Congenital Defect / How does your child travel in a car?
Chest Pain /  Forward Facing Car Seat Rear Facing Car Seat
Murmur / Booster Seat Seat Belt Tethered wheelchair
Cardiac-Apnea Monitor / Are there any smokers living in your home?
 Other______/  Yes No
Cardiologist / Do you have concerns about safety in your home?
 Yes No
ALL OTHERS NEGATIVE

Reviewed by: ______Date: ______

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Myelomeningocele 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 /  VP Shunt
 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: Both Parents 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: ______

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