ParentalquestionnaireDec07 09

8/14/2019 ParentalquestionnaireDec07 09

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Patients questionnaire ATT clinic- December 07

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Parental Questionnaire (CONFIDENTIAL)

E-mail_____________________________Date__________________________Phone #_____________

CHILD:Name:_______________________________Age:_________Birth Date:_________________________

Current Weight (kg)__________________________________________________________________________

Present height________Weight_______Size in relation to same age peers_________________________

Address:_____________________________________________________________________________________

_____________________________________________________________________________________________

GP (including address):_______________________________________________________________________

Fathers Name:______________________________________________________________________________

Mothers Name:_____________________________________________________________________________

Siblings, Gender and Ages:___________________________________________________________________

List those living in primary home:______________________________________________________________

List those living in secondary home:___________________________________________________________

FATHER:Medical history:______________________________________________________________________________

Immune illnesses (e.g.): Allergy, Asthma, urticaria, auto-immune, psoriasis: _____________________________________________________________________________________________

Illnesses in paternal family:____________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Any history of autism, ADHD, Bipolar, Schizophrenia, depression, addictions, Alzheimer disease,MultipleSclerosis?_____________________________________________________________________________

_____________________________________________________________________________________________

MOTHERGeneral Health:______________________________________________________________________________

Medical history:______________________________________________________________________________

Immune illnesses (e.g.): Allergy, Asthma, urticaria, auto-immune, psoriasis: _____________________________________________________________________________________________ Illnesses in maternal family:___________________________________________________________________

_____________________________________________________________________________________________ _____________________________________________________________________________________________

Any history of autism, ADHD, Bipolar, Schizophrenia, depression, addictions, Alzheimer disease,MultipleSclerosis?____________________________________________________________________________

_____________________________________________________________________________________________


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How many amalgam fillings?_________________________________________________________________ When placed?______________________________________________________________________________

Any medical procedures during pregnancy?__________________________________________________

Any unusual event during pregnancy?________________________________________________________ ____________________________________________Rh neg?_________________________________________

Childs Birth place:__________________________________Type of delivery:_________________________ Difficulty of Labor:____________________________________________________________________________ Condition at birth:____________________________________________________________________________ APGAR:______Wt:_____Mothers age at delivery:_______________________________________________

Other event during delivery?_________________________________________________________________ Any amalgam fillings placed in mother during pregnancy or breast feeding?___________________

CHILD

Breast Fed/How long:________________________________________________________________________

Allergies____________________________________Injuries___________________________________________

_____________________________________________________________________________________________

Infections_________________________________________Fevers_____________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Treatment with antibiotics____________________________Reactions_______________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Surgeries, tubes in ears_______________________________________________________________________

Seizures: Age of onset, type, accompanied by fever, timing re illnesses, injuries, vaccinations:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________ Vaccination history and describe any adverse reactions or changes in behavior after receiving

(if need be detail on separate sheet, you can include full medical vaccination record):

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________


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_____________________________________________________________________________________________

If abnormal reaction to vaccination, have the events been reported and noted by your childs

doctor?

_____________________________________________________________________________________________

Has your child had a disorder since birth, or later onset? Please describe First sign of concern

and outline development of condition?

____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Closest personal bond (usually):______________________________________________________________

When NeverAge at onset of delays/problemsAge at onset of regressionSitting upCrawlingPulled to standWalked alonePotty trainedDry at night

First wordsSpoke clearlyLost languageLost eye contact

Amalgam fillings; how many and what age?__________________________________________________


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PAST AND CURRENT MEDICAL HISTORY

General Skin Cont'd ImmunePoor temperature control Oily skin Allergic RhinitisNight sweats Pale skin AsthmeStiffen body/ different posture Psoriasis BronchitisUnusual flexibility Rashes Chemical sensitivitiesFatigue Warts Chest congestionFast heart rate Chronic coughHigh pain tolerance Eyes Food allergiesJoint pain Dark circles under eyes Frequent cold infectionsHeadache Dilated pupils Hay feverUpper body pain Divergent gaze Lymph nodes enlargedRinging in the ears Poor eye contact Seasonal allergiesSeizure Visual stimsTics Yeast

GI Athlete's footSkin Abdominal pain Feet cracking, peelingAcne Bloating Nail fungusBody odor Burping Red ring around anusBlotchy skin Colic Ring wormCold Sores Constipation ThrushChicken skin Diarrhea VaginitisBurns easy FlatulenceCradle cap Stools/ BulkyDandruff Stools/ BloodyDry skin Stools/ FloatEczema Stools/ Light colorFlushing Stools/ MucusGums blleed Stools/ MushyHives Stools/ Strong odorItchy skin Stools/ Undigested food

Stools/ formedStools/ softStools/ liquid

P: Past, C: Current

DIET

Eating Patterns: Infant_______________________Formula base (milk, soy, etc)_____________________

Toddler______________________________________________________________________________________

PICA? (eating/chewing non eatable things)___________________________________________________

Favorite foods___________________________Most disliked foods__________________________________


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List any special diets and reactions/results_____________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________ ________________________________________________

Child positioning themselves as to apply pressure on lower abdomen, with pieces of furniture

(Sofa, arm chairs) or on the floor.

Please provide details

Details of any dietary interventions


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CURRENT DIET

Type of food Helpings per week: 0

Helpings per week: 1-3

Helpings per week: 3-5

Helpings per week: >5

Bread

PastaRicePotatoesGreen vegetableOther vegetablesLettuceFruitsMeatChickenFishCheese

SweetsBiscuitsChocolateJuiceFizzy drinksCrispsWater Milk Rice milk Soy Milk Other drinksFast food

Type of diet

How would you rate your child diet?Description Yes Moderately so NoRestrictedSelf restrictedPicky eater Broad dietOrganic foodGF/CF dietGF/CF soy free/corn free

GF/CF soy free/corn free/ sugar free

LABORATORY TESTINGS:

Results of chromosomal studies: ______________________________________________________________

Fragile X (state if done or not and what is the result)____________________________________________

EEG:_____________________________________________MRI:_______________________________________


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List any laboratory studies undertaken and results (date and positive or negative if dont know

actual values):

Organic acid_________________________________________________________________________

Stool analysis or other gastrointestinal studies___________________________________________ Urinary peptides______________________________________________________________________

Immune function tests_________________________________________________________________

Fatty acid analysis____________________________________________________________________

Heavy metals studies__________________________________________________________________

Amino acids, Vit. Zinc, other nutrients__________________________________________________

Hair analyses_________________________________________________________________________

Any others not listed__________________________________________________________________________

_____________________________________________________________________________________________

List any medications in past and currently taking, times and doses______________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

List any nutrients/vitamins currently taking, doses, any reactions (Use separate sheet if need be)

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Do you have a personal opinion as to why your child is developmentally delayed?______________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please give any other information that might be helpful in evaluating your child: please send a

current photo with siblings/family if possible.___________________________________________________

OTHER HEALTH ISSUES:

Sleeping patterns:____________________________________________________________________________

Nightmares:__________________________________________________________________________________

Place of Education :__________________________________________________________________________

Disruptive/anti-social behavior in public_______________________________________________________

Teacher comments/reactions:________________________________________________________________

_____________________________________________________________________________________________

Describe general personality:_________________________________________________________________

Mood swings:________________________________________________________________________________


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Hyper or hypoactive?________________________________________________________________________

Inconsolable crying spells:____________________________________________________________________

Friends: Make easily: __________________________________________Keep:_________________________

Relation to Adults:___________________________________________________________________________ Imagination pattern:_________________________Imaginary friends:_______________________________

Handedness:________________________________________________________________________________

Eye contact (rate as good, moderate issue, serious issue):_____________________________________

Affection (please state towards whom or what):_______________________________________________

Alertness:____________________________________________________________________________________

Favorite activities:___________________________________________________________________________

Repetitiousness______________________________________________________________________________

Relation to animals:__________________________________________________________________________

Fears of dark, water, strangers:________________________________________________________________

Favorite object(s):_________________________Reaction to change______________________________

_____________________________________________________________________________________________

Unusual fears/phobias/attachments:__________________________________________________________

_____________________________________________________________________________________________

Sense of humor:______________________Self-sufficiency:_________________________________________

Toilet Trained: Urinary Yes/No Bowel Movements: Yes/No

Self Directed Aggressive Behavior: Yes/No

Self Injury Behaviour: Yes/No Specify:__________________________________________

COMMUNICATION, SENSORY AND COGNITIVE SKILLS

Please describe the childs skills in the following areas:

Playskills: _____________________________________________________________________________________________ _____________________________________________________________________________________________

Self care skills: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________


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Understanding of language: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Use of language:

Uses Single Words: Yes/No How many: _____ Uses Sentences: Yes/NoUses Successive Sentences: Yes/NoOverall speech is functional in context: Yes/No

Any additional comments

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Use/understanding of non verbal communication:

PECS Yes/NoSign Language Yes/NoAny additional comments

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Level of interaction (e.g. with sibling/peers/familiar adults _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

_____________________________________________________________________________________________

Sensory issues (e.g. intolerance of particular sounds, smells, visual stimulus) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________


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Self stimulatory behaviours: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Aggressive or tantrum type behaviours (please clarify if this is appears as out of the blue of asresponse of demand/ or change placed on the child)

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Details of any school/nursery placement: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Details of input from other professionals (e.g. speech and language therapist): _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________

What concerns you the most? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________

What are your childs favourite activities? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

What do you do to reward your child?


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_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Any other comments

_____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

Please enclose copies of any relevant information for example diagnosis, assessments or reports

Research Agreement:

I agree for the patients laboratory results and family history to be used anonymously for research proposes.

Date: Signature:

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ParentalquestionnaireDec07 09