Date of Appointment: - massgeneral.org · Web viewPediatric. Patient Information. Form. You may download the Pediatric Patient Information Form and enter your responses electronically

1 Maguire RdLexington, Massachusetts 02421

781.860.1700

Pediatric Patient Information Form

You may download the Pediatric Patient Information Form and enter your responses electronically. You may also print the form and enter handwritten responses.

You may either email the completed form to us at [email protected] or mail the completed form to our address provided on the form itself. Once we receive and review the completed Patient Information Form, we will call you to either schedule an appointment or refer you to another provider(s) that may better serve your needs. This process can take up to three weeks.

Please be aware: For all patients age 4 and under, an office note from the Primary Care Provider

listing the specific concerns and recommendation for an evaluation for autism is required to obtain insurance authorization. Pleased submit this note with your completed intake packet. Returning your packet without a note from your Primary Care Physician will delay the scheduling process.

Although you may have been referred to a specific provider, all New Patient Packets are reviewed by the team to determine which of our providers will be the best fit for the patient. Once reviewed, we will then call you to schedule with that provider.

The Lurie Center is scheduling new patient appointments out 6 to 12 months for some services but we keep a Wait/Cancellation list and often are able

The Lurie Center does not provide primary care services. For patients outside of Massachusetts who seek medication management we require,

at minimum, annual visits to the Lurie Center. The regulations allowing physicians to provide consultation to patients outside of Massachusetts vary by state and frequently change. Therefore, an in-state provider may need to prescribe medications.

Before you complete the form: Since this initial form is so lengthy, we recommend that you confirm with your insurance company that the providers of the MGPO (Mass General Physician Organization) are covered through your insurance. Please also confirm that there are no exclusions for autism spectrum disorder.

Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766

Page 1 of 15 Form Version Jan 2018

mailto:[email protected]

Section 1. Child Demographic Information

First Name Middle Last

Date of Birth Age

Home Street Address

City/State Zip Code

Parent/Guardian Name(s)

Preferred Phone Alternate Phone

Email Address

Primary Care Physician: PCP Phone Number:

Address:

Please check this box if your PCP is a Partners HealthCare Provider

___________________________________________________________________________________________

Parents’ marital status Single Married Separated Divorced Other

Do parents legally share medical decision-making responsibilities? Yes No

If not, who is the child’s legal guardian?

Note: Documentation of guardianship, custody agreement, and/or medical decision rights must be submitted

with this intake form. Please take note, the parent or legal guardian must attend the in initial visit.

If parents do not live at one address, please provide contact information for the non-custodial parent:

Non-custodial Parent Name

Non-custodial Parent Address

Non-custodial Parent Preferred Phone

Visit reports should be sent to both addresses Yes No

Child’s Living Situation Family Home Group Home Residential School Other

If your child is living at a group home, school, or other site, please provide contact information below:

Has the patient ever been in trouble with the police? Yes No If yes, please describe

Is the patient currently incarcerated in police custody? Yes No

If yes, please provide information below:

Institution Name

Institution Address

Contact Name Contact Phone

Institution Fax Email



List parents and anyone else living in your child’s primary home:

Relation Name Age Level of Education Occupation

Parent

Parent

Sibling(s)

List immediate family (parent or brother or sisters NOT living in your child’s primary home):

Relation Name Age Level of Education Occupation

Parent

Parent

Sibling(s)

Section 2. Primary Concerns and Diagnostic History

Who referred you to the Lurie Center?

What are the major concerns that you would like the Lurie Center to address?

What is your primary goal for this appointment?

Has your child previously received a neurological, developmental, autism spectrum or any mental health

diagnoses? Yes No

If yes, please list diagnoses below:

Previous Diagnoses Date of Diagnosis Diagnosed by:

1.

2.



3.

4.

5.

6.

7.

What other medical providers does your child see outside the Lurie Center?

Section 3. Pregnancy/Birth History

If your child was adopted and you have no information on the pregnancy or birth history, please check this box and proceed to Section 4. History of infertility? Yes No

Hormone treatment or birth control use prior to pregnancy? Yes No

Conception assisted? Yes No

If yes, check all that apply:

Artificial Insemination In vitro fertilization Fertility drug

If fertility drug used, please list name of medication(s):

During pregnancy: Excessive nausea/vomiting? Yes No

Gain of more than 35 lbs? Yes No Gain of less than 10 pounds? Yes No

Special diet? Yes No If yes, reason:

RH incompatibility? Yes No If yes, treated with Rhogam? Yes No

Alcoholic beverages consumed during pregnancy? Yes No

If yes, please list alcohol type/frequency/number of drinks per day:

Recreational drug use during pregnancy? Yes No

If yes, please list types of drugs other than alcohol:

Cigarette smoking during pregnancy? Yes No

Prenatal vitamins during pregnancy? Yes No

Medications other than vitamins during pregnancy? Yes No

If yes, please list:

High blood pressure during pregnancy? Yes No

Severe headaches during pregnancy? Yes No

Spotting or bleeding during pregnancy? Yes No

Physical or emotional trauma to the mother during pregnancy? Yes No

If yes, please explain:



Ultrasounds during pregnancy? Yes No

If yes, how many:

Amniocentesis? Yes No

Premature labor or concerns about premature labor? Yes No

If yes, how was it treated?

Any significant illnesses during pregnancy? Yes No

If yes, please specify:

Any significant infections during pregnancy? Yes No


Depression during pregnancy? Yes No

Other medical problems during pregnancy? Yes No


Any concerns about fetal health during pregnancy? Yes No


Were this child’s movements different than in other pregnancies? NA Yes No


Length of pregnancy:

Length of labor:

Induced? Yes No

Anesthesia? Yes No

Birth was Normal Cesarean Breech Twins or multiple births

Were forceps used? Yes No

Did baby need medical assistance to start breathing? Yes No


Apgar scores, if known: 1min 5min

Did mother have complications? Yes No


Section 4. Newborn History

Birth weight: Birth city:

Was baby in the special care nursery? Yes No


Was the newborn physical exam normal? Yes NoLurie Center for Autism/1 Maguire Road, Lexington, MA 02421

Phone 781.860.1700/Fax 781.860.1766Page 5 of 15 Form Version Jan 2018


Did baby go home from hospital with the mother in a typical amount of time? Yes No

If no, please specify:

Check any of the following the baby experienced during the first month of life:

excessive crying severe diarrhea skin rash jaundicenursing/feeding difficulty injury infection convulsions/seizurescyanosis (blue baby) other; if other, please describe:

What was the child like to care for as an infant?

Section 5. Developmental History

A) Motor Skills

Do you remember any specific or generalized delays in motor development? Yes NoIf yes, were these motor delays generally: Mild Moderate SevereIf able to recall, please state the age at which your child first:smiled not yet If yes, age: drew with crayon not yet If yes, age: followed with eyes not yet If yes, age: stood alone not yet If yes, age: reached for objects not yet If yes, age: took first steps not yet If yes, age: rolled over not yet If yes, age: walked alone not yet If yes, age: sat with support not yet If yes, age: ran not yet If yes, age: sat without support not yet If yes, age: rode tricycle not yet If yes, age: crawled not yet If yes, age: rode bicycle not yet If yes, age: ate with a spoon not yet If yes, age: State any concerns you have regarding your child’s strength or motor coordination skills:

Does your child fatigue easily? Yes No

Does your child move in an unusual or clumsy manner? Yes No


Does your child use any special equipment (wheel chair, braces, etc.)? Yes No

If yes, please specify: Your child’s hand preference: Right Left Not established Ambidextrous

B) Communication

Number of words your child can say:

Number of words your child communicates non-verbally or with sign language:

How does your child mainly communicate? Please check all that apply below:

crying/vocalizing single words typing points

gestures signing babbling two-word phrases



sentences rote phrases electronic device making up words

reversing pronouns pulls person to object of interest

picture communication system

unusual volume, rate, rhythm and/or intonation

How does your child use speech? Please check all that apply below or: No speech

to express needs to express emotions to talk about things

to echo others to interact with others inappropriately

Did your child babble as a baby? Yes No

Age when your child spoke first intelligible word? Age: Not yet

Age when your child spoke 2-7 words? Age: Not yet

Age when your child spoke short phrases? Age: Not yet

Did your child begin to use words then stop?

If yes, at what age stopped? If restarted at what age?

Yes No

Does your child speak clearly (articulate)? Yes No

Does your child respond appropriately when name is called? Yes No

Does your child follow simple commands? Yes No

Does your child spontaneously smile? Yes No

Does your child respond to a smile? Yes No

Does your child look for approval or acknowledgement? Yes No

Do you have any concerns about your child’s speech/ language?


Yes No

Please list all languages spoken at home:

C) Sensory

Is your child sensitive to sound?

normal overly sensitive under sensitive other, please explain:

Is your child sensitive to odors?


Is your child sensitive to taste?




Is your child sensitive to sight?


Is your child sensitive to being touched?


Does your child avoid playing with messy substances (finger paints, paste, etc.)? Yes No

If yes, please explain: Does your child dislike the feeling of certain types of clothing/tags or material textures? Yes No

If yes, please explain: Does your child seek sensory input/stimulation? Yes No


D) Feeding and Nutrition

Does your child eat too quickly? Yes No

Do you think your child may have acid reflux? Yes No

Does your child regurgitate frequently? Yes No

Describe any difficulty your child has had with sucking, chewing, swallowing or excessive drooling

past: present:

Any unusual food habits?

Any concerns about your child’s nutritional status or weight?

E) Self-Help Skills

Please check whether your child has the listed self-help skills. If yes, list age at which skill first developed.

toilet trained (bladder)? not yet If yes, age: button clothes? not yet If yes, age:

toilet trained (bowel)? not yet If yes, age: tie shoelaces? not yet If yes, age:

able to dress self? not yet If yes, age: bathe/shower? not yet If yes, age:

able to undress self? not yet If yes, age: choose suitable clothes? not yet If yes, age:

Do you have any specific concerns about your child’s self-help skills? Yes No


F) Social/Emotional Growth

Does your child or has your child ever done the following? Please check all that apply:

use someone else’s hand as a tool point



offer comfort point to express interest

seek comfort point with eye gaze to communicate

experience difficulty with peers use gestures

inappropriate facial expression nod or head shake

have pretend or make believe play spontaneously imitate

play “peek a boo”/ “I’m going to get you” play games with doll etc.

have a variety of play interests excessive and or unusual interests

respond to name orient toward sound

focus on parts of toys or nonfunctional materials in play

Has your child experienced any of the following behavioral challenges in the past or currently?

If the behaviors were in the past, at what age did they stop?

Behavior Current

Behavior

Past,

Age StoppedBehavior Current

Behavior

Past,

Age Stopped

difficult to discipline current difficultly focusing current

gets upset easily current destructiveness current

have temper tantrums current self-injurious current

unusually active current repetitive behavior/play current

unusually inactive current repetitive body movements current

thumb sucking current repetitive hand movements current

preferring to be alone current repetitive use of language current

unusual difficulty with siblings current difficulty sleeping current

unusual difficulty with peers current nightmares current

difficulty with opposite sex current nail biting current

bed wetting current masturbating current

aggression towards others currently skin picking current

What does your child like to do with free time?

Does your child share enjoyment by: showing sharing smiling talking

What are your child’s favorite activities?

What are your child’s favorite toys or objects?

Does your child have any unusual or intense interests?

Does your child prefer to play with: toys other children



Does your child prefer to play with: groups individual activities

Does your child have meaningful friendships? some none one or two many

Are your child’s friends: older younger same age mixed ages

When around children, does your child: watch approach respond share vocalize

Section 6. Childhood Medical History

Check any of the following conditions your child has experienced and list their age at time of event and any complications:

Disease/Problem Age If complications please explain?

Measles, Mumps, or Rubella

Chickenpox

Frequent infections (ex. Strep throat)

Meningitis/Encephalitis

Seizures/convulsion

Fainting spells

Headaches/migraine

Sleep disturbance

Asthma

Frequent falls

Accidents/head trauma

Unusual severity of common illness

Ear infections

Hearing problems

Constipation/diarrhea

Vaccine reaction

Rashes

Visual Problems

Head injury/ Traumatic brain injury

Loss of consciousness

Other

Has your child had any hospitalizations? Medical—Yes No Psychiatric-- Yes No

If yes, please list date, reason and approximate number of days of hospitalization in the table below:

Date Reason Estimated Days



Has your child had any surgical procedures? Yes No

If yes, please list approximate date and reason for surgeries in the table below:

Date Reason for Surgery

Please check any medical diagnostic tests your child has completed:

MRI EEG CT Scan Blood/Lab work Genetic work-up Other, specify:

Does your child have any food allergies? Yes No


Does your child have any special dietary restrictions? Yes No


Is your child taking any vitamins and supplements? Yes No


Please list all current and past medications and their dosages:

Medication Dose Current Past

Does your child have any medication allergies? Yes No


Does your child have any side effects to medications? Yes No


Has your child had a vision exam? Yes No

If yes, when and what results?



Has your child had a hearing test? Yes No

If yes, when and what results?

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

Does your child have regular dental visits? Yes No

Section 7. Family Medical History

If any of your child’s immediate biological family or relatives has experienced any of the following conditions,

please check the condition, write their relationship to your child, and provide more details, if possible.

Condition Relationship to child Comments

Seizure disorder

Autism/PDD/Asperger’s

Cerebral palsy

Mental retardation

Language delay/ communication problems

School difficulties (include grades repeated)

Learning disability

Muscular weakness

Deformities

Multiple Sclerosis

Alcoholism/substance abuse

Emotional/ Psychiatric problems

Other serious illness

High blood pressure

Heart disease

High cholesterol

Stroke

Diabetes

Cancer

Thyroid problems

Asthma

Anxiety Disorders

Depression



Anxiety

Bipolar Disorders

Schizophrenia/Psychosis

Attention-Deficit Hyperactivity Dx (ADHD/ADD)

Lupus

Rheumatoid Arthritis

Crohn’s Disease

Ulcerative Colitis

Psoriasis

Genetic Disorder

8. Educational History

Current Grade:

Last school attended:

How long attended?

Did your child or does your child currently attend: Early intervention Day Care

Please check below all school types your child has attended and also check the classroom setting for each school.

School Type Classroom setting for each school type

Public Private Parochial Special

Collaboration

Regular Integrated Self-Contained

Mainstream/Inclusion

Preschool

Elementary 1

Elementary 2 (if changed school)Elementary 3

(if changed school)

Middle School 1

Middle School 2

(if changed school)

Middle School 3

(if changed school)

High School 1

High School 2

(if changed school)

Name of your child’s current teacher and/or case worker:



If still in school, name of Director of Special Education: If still in school, how is your child doing in school, relative to last year?

Please check below all services your child is receiving or has ever received as part of an IEP, ISP or 504 plan:

Therapy In school Out of School Currently Previously

Speech-Language Therapy

Physical Therapy

Occupational Therapy

Counseling

Resource Room

Summer Services

Other: Diagnostic Testing (Please list below the most recent school tests, CORE/Team evaluations, etc.):

Date Completed Type of Test Conclusions/Recommendations

What supports are your child and family currently receiving?

None Respite Extended program after school

Extended family Advocacy Other

Section 9. Please share any additional concerns or questions that you have:

Please send these additional documents with your Intake Packet:

o For all patients age 4 and under, an office note from the Primary Care Provider listing the specific concerns and recommendation for an evaluation for autism is required to obtain insurance authorization. Pleased submit this note with your completed intake packet. Returning your packet without a note from your Primary Care Physician will delay the scheduling process.

o If applicable, documentation of guardianship, custody agreement, and/or medical decision rights.



The Lurie Center, as part of Massachusetts General Hospital and Harvard Medical School, is committed to the missions of clinical care, research and education. May our research staff contact you about educational or research opportunities at the Lurie Center? Yes No

Name of person completing this form Relationship to child Date

Attach your completed form to an email and send to:

[email protected]

Or mail to:New Appointments

Lurie Center1 Maguire Road

Lexington, Massachusetts 02421Additional Information

o Once we receive your completed New Patient Information Form, we will contact you within 10 business days to either schedule an appointment or refer you to another provider(s) that may better serve your needs.

o If you have any questions, please call 781.860.1708 and speak to Maggie Pagan, our New Appointment Coordinator. You may also contact us via email at [email protected].



mailto:[email protected]

Documents

Date of Appointment: - massgeneral.org · Web viewPediatric. Patient Information. Form. You may download the Pediatric Patient Information Form and enter your responses electronically