PWS PATIENT INTAKE FORM
Patient Name: / Address:
Date of Birth: / Primary Contact Person: / Date of Form Completion:
Best Contact Phone: / Our physician will contact you to review your information. / Best Day and Time:
Reason for Admission/Current Medical Symptoms:
PAST MEDICAL HISTORY
Prader-Willi Syndrome / Age of Diagnosis: / Down Syndrome
I.Q. Test Score: / Other:
Genetic Testing:
UPD / Imprinting / Deletion / Other:
Obesity:
Current Weight: / Height: / BMI:
Obstructive Sleep Apnea:
CPAP / BiPAP / Date of Titration:
Skin:
Cellulitis / MRSA / Skin Picking / Other:
Respiratory:
Asthma / COPD / Frequent Pneumonia / Use of O2
Pulmonary Function Studies – Dates:
Diabetes Mellitus:
Type 1 / Type 2 / Controlled / Not Controlled
Hemoglobin A1c: / Date Last Tested:
Cardiovascular:
Congestive Heart Failure / Myocardial Infarction / Hypertension
Hyperlipidemia / Abnormal Rhythm / Lymphedema
Musculoskeletal:
Fracture / Osteoporosis / Scoliosis
Gastrointestinal:
Constipation / Diarrhea / Gastroparesis
Difficulty Swallowing / Modified Barium Swallow / Rectal Bleeding
Genitourinary:
Urinary Incontinence / Bedwetting / Other
Neurology:
Seizures / Headache / Other
Endocrine:
On Growth Hormone / Hypothyroidism / Hypogonadism
Adrenal Insufficiency / Panhypopituitarism / On Testosterone / On Hormone Replacement
Enter any other medical conditions not mentioned above
Surgery
Psychiatric / Behavioral Health History
Previously diagnosed or currently being treated for:
Psychosis / Anxiety Disorder / Depression/Mood Disorder
OCD / ADD/ADHD / Self Injurious Behavior
Current or previous intention to harm self or others
What do you do when not happy?
How many times per week: / Yell/Shout Throw Objects Become Physically Aggressive
___ Yell/Shout _____Throw Objects ____Become Physically Aggressive
Other Behavior:
Previous Admission at The Children’s Institute Please list dates:
Has the patient ever: / Eloped Set Fire Been arrested/Had legal charges
Demonstrated sexually inappropriate behavior
Psychiatric Hospitalizations/Date:
Medications for Mental Health Issues:

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Social History
Alcohol Use: Daily Occasional
Tobacco Use: How Long How OftenThe Children’s Institute is a nonsmoking facility
Recreational drug use: Pain medication abuse:
Diet
Type of diet:
Calorie count:
Food security:
Allergies/intolerance to food:
Problems when eating? / Choking Coughing Food stuckWear dentures
Missing Teeth
Current Level of Functioning
Is the patient able to do activity of daily living
Feeding
Toileting
Selecting proper attire
Grooming
Maintaining continence
Putting on clothes
Bathing, walking and transferring / Yes
Yes
Yes
Yes
Yes
Yes
Yes / No
No
No
No
No
No
No
Agency Involvement
Registered with Department of Developmental Disabilities? Yes No
Name of Organization:
Contact Name:
Address: / Phone Number:
Fax Number:
Services Received:
Receive a medical waiver? Yes No
Current School or Vocational Status
Currently attends workshop/school / Does not attend workshop/school
If attending school:
Type of classroom:
RegularSpecial Education
Home-school
Grade Level: / Is there a current IEP? Yes No
Please provide copy, if yes.
Date Initiated:
To be reviewed:
Name of School:
Contact Name:
Address: / Phone Number:
Fax Number:
Family Status
Guardianship Status / Primary Caregiver(s): / Parent(s) Names:
Living arrangements:Parents: Yes No Group Home Yes NoFuture
Name/Contact Information:
Patient/Family Goals
What is your primary goal for admission?
Discharge Disposition

What is the patient’s discharge plan?

/

Does Guardian support this plan?

Yes No
Medications Currently Prescribed
Medication Name / Dose / Route / Frequency / Reason for taking / Date Started / Prescriber
Primary Physician and Specialist Information
(CI will be requesting records from these professionals)
Physician / Address / Phone / Fax
Primary Care Physician/Pediatrician
Endocrinology
Genetics
Cardiology
Pulmonology
Psychiatry/ Psychology
Neurology
Gastroenterology/Nutrition
Orthopedics
Other
Recent Hospitalizations (including ER visits)
Hospitalization / Medical or Psychiatric? / Date/LOS / Complaint/Reason

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