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Secure Pediatric Neurology History Form - Please do not use all caps.

Patient`s Last Name*

Patient`s First Name:*

Date of Birth*

Grade

Sex*

This Form Filled Out By*

Your Relationship to the Child*

Referring Physician*

What are you concerned about with your child?*

PREGNANCY AND BIRTH HISTORY
Full Term or Premature?*

What happened during the pregnancy?*

Labor & Delivery/C Section*

How many pounds did the child weigh at birth? Enter 0 if you do not recall.

How many additional ounces did the child weigh at birth? Enter 0 if you do not recall.

Number of Days in the Hospital*

Did the baby come home with medications?*
Yes
No

with a monitor?*
Yes
No

Please Add Any Details re the Pregnancy, Labor, Delivery, and Time in the Hospital not covered above

PREVIOUS DIAGNOSES - CHECK ALL THAT APPLY
ADHD

seizures

asthma

concussion

febrile seizures

heart murmur

migraines

scoliosis

fractures

Tourette

stitches

fainting

hearing loss

glasses/contacts

frequent ear infections

sleep apnea

cerebral palsy

Other Condition or Explanation of Checked Item Above:

HOSPITAL ADMISSIONS SINCE BIRTH, SURGERIES, PROCEDURES including tonsils,adenoids, ear tubes
Any hospital admissions since birth, surgeries, procedures (eg, tonsils, adenoids, ear tubes) ?*
Yes
No

DETAILS - SKIP IF NO HOSPITALIZATIONS, PROCEDURES, OR TESTS

TESTS: EEG*
not done normal abnormal 

CAT SCAN/MRI*
not done normal abnormal 

DEVELOPMENT
Development is/was*

FURTHER DEVELOPMENTAL MILESTONES
Toilet Training*
Is toilet trained. Is not yet toilet trained. 

Tricycle/Bicycle*
Does not pedal a tricycle. Rides a tricycle. Rides a bicycle without training wheels. Rides a bicycle with training wheels. 

Shoe Tying*
Ties shoes well. Does not tie shoes. Ties shoes loosely. 

Handwriting*
Possesses neat handwriting. Has somewhat messy handwriting. 

FAMILY HISTORY - PLEASE FILL IN DETAILS RE SEIZURES, HEADACHES, LEARNING DIFFERENCES, SUDDEN DEATH.
Seizure*
Neither parent
Mother
Father
Both parents

Headache*
Neither
Mother
Father
Both

Learning Difference*
Neither
Mother
Father
Both

Inattentive As a Child*
Neither parent
Mother
Father
Both parents

Has Relatives with Problems Similar to Patient*
Neither
Mother
Father
Both

Has Relatives Who Died Suddenly/Unexpectedly?*
Neither
Mother
Father
Both

Additional Information Re Mother and Mother`s Relatives

Additional Information Re Father and Father`s Relatives

Well Siblings

Siblings with illnesses



Other Condition Not Listed

Siblings with illnesses



Other Condition Not Listed

SOCIAL HISTORY
Mother`s occupational status:*

Mother`s occupation

Father/Partner`s Work Status*

Father/Partner`s occupation

Parents` Marital Status*

SCHOOL HISTORY
Activity Level*
overactive. underactive. possessing a normal activity level. 

Grades Repeated

Grade Repeated

Homework

Friendships

Speech Therapy Frequency
Speech therapy occurs once per week
Speech therapy occurs twice per week
Speech therapy occurs three times per week
Speech therapy occurs four times per week

Occupational Therapy Frequency
Occupational therapy occurs once per week
Occupational therapy occurs twice per week
Occupational therapy occurs three times per week
Occupational therapy occurs four times per week

Physical Therapy Frequency
Physical therapy occurs once per week
Physical therapy occurs twice per week
Physical therapy occurs three times per week
Physical therapy occurs four times per week

Counseling Frequency
Counseling occurs once per week
Counseling occurs twice per month
Counseling occurs once per month

EDUCATIONAL ASSISTANCE:
ABA therapy is provided

Basic skills is provided

504 plan is in place

Resource room is provided

Individual aide is of assistance in the classroom

A shared aide is present in the classroom

Social skills is provided

Inclusion classes are provided

MEDICATIONS
Current Medications:

Previous Medications:

Allergies to Medications:

REVIEW OF CURRENT SYMPTOMS
GENERAL:*
All choices in the GENERAL section are NO. Please go to the next ?.
At least one answer is YES; please check the box(es) that apply.

fatigue

fever

weight loss

weight gain

pale

_________________________________________________________________________________________________________________________________________________________________________________
EYES, EARS, NOSE, AND THROAT*
All choices in this section are NO. Please go to the next question.
At least one answer is YES; please check the box(es) that apply.

trouble seeing

congestion

hearing loss

allergies

watery/itchy eyes

throat clearing

__________________________________________________________________________________________________________________________________________________________________________________
HEART:*
All choices in the HEART section are NO.
At least one answer is YES; please check the box(es) that apply.

fast heart rate

chest pain

murmur

__________________________________________________________________________________________________________________________________________________________________________________
LUNGS:*
All choices in the LUNGS section are NO.
At least one answer is YES; please check the box(es) that apply.

cough

wheeze

__________________________________________________________________________________________________________________________________________________________________________________
DIGESTIVE SYSTEM:*
All choices in the DIGESTIVE SYSTEM section are NO.
At least one answer is YES; please check the box(es) that apply.

nausea

constipation

diarrhea

vomiting

stomach aches

___________________________________________________________________________________________________________________________________________________________________________________
ELIMINATION:*
All choices in the ELIMINATION section are NO.
At least one answer is YES; please check the box(es) that apply.

up at night to urinate

urinary accidents

bowel accidents

urinates frequently

__________________________________________________________________________________________________________________________________________________________________________________
ENDOCRINE/HORMONES*
All choices in the ENDOCRINE/HORMONES section are NO.
At least one answer is YES; please check the box(es) that apply.

decreased appetite

increased appetite

drinks too much

irregular periods

__________________________________________________________________________________________________________________________________________________________________________________
MUSCULOSKELETAL:*
All choices in the MUSCULOSKELETAL section are NO.
At least one answer is YES; please check the box(es) that apply.

weakness

joint pain

cramps

falls

back pain

numbness

___________________________________________________________________________________________________________________________________________________________________________________
SKIN*
All choices in the SKIN section are NO.
At least one answer is YES; please check the box(es) that apply.

rash

hair loss

birthmarks

itching

hives

__________________________________________________________________________________________________________________________________________________________________________________
NEUROLOGICAL*
All choices in the NEUROLOGICAL section are NO.
At least one answer is YES; please check the box(es) that apply.

headache

tics

faints

double vision

staring spells

__________________________________________________________________________________________________________________________________________________________________________________
MOOD:*
All choices in the MOOD section are NO.
At least one answer is YES; please check the box(es) that apply.

anxiety

depression

hallucination

irritable

stress

alcohol use

substance abuse

__________________________________________________________________________________________________________________________________________________________________________________
SLEEP:*
All choices in the SLEEP section are NO.
At least one answer is YES; please check the box(es) that apply.

naps

leg pains

not awake a.m.

snores

apnea

up middle night

too sleepy

insomnia

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