Patient and Family Education

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Neurodevelopmental Clinic Family Questionnaire Today’s date: ___________________________________________________________________________

Child’s name: _________________________________________ date of birth: ______________________

Guardian: ☐both parents ☐mother ☐father ☐DSHS ☐Other:_______________

Current Concerns: What are your primary concerns about your child? _____________________________________________

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When did you first have these concerns? _____________________________________________________

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What have you been told about your concerns? ________________________________________________

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What have you been told about your child’s future or any diagnoses? _______________________________

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Birth and Early Infancy History Age of mother at time of birth______________ Was the pregnancy planned? ☐Unknown ☐No ☐Yes

Does the mother have any history of miscarriage or still birth?____________________________________

Any difficulty becoming pregnant? ☐Unknown ☐No ☐Yes : _______________________________

Was the mother exposed to any of the following while pregnant? ☐Drugs ☐Alcohol ☐Tobacco ☐Prescription medications ☐X-Rays ☐Unknown

If yes, please list medications/substances:_____________________________________________________

Did the mother experience any significant illness or injury during pregnancy? ☐ Unknown ☐No ☐ Yes

If yes, please explain: _____________________________________________________________________

Labor and Deliver: ☐ Vaginal ☐C-section ☐Forceps ☐Vacuum assist Was the delivery difficult? ☐Unknown ☐No If yes, please explain: ______________________________

______________________________________________________________________________________ Were there any problems after birth? (examples: jaundice, need for oxygen, infections, feeding problems, seizures) ☐Yes ☐No If yes, please explain:________________________________________________

______________________________________________________________________________________ Were there any difficulties during infancy? (examples: excessive crying, vomiting, “colic,” poor feeding): ☐Yes ☐No If yes, please explain: _____________________________________________________________________

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Medical and Physical History: Does your child have any allergies? : ☐No ☐Yes ☐Unsure ___________________________________ Is your child having any sleep issues? ☐No ☐ Yes: ☐restless ☐snoring ☐pauses ☐night awakenings ☐other _____________________________________________________________________

Please explain: __________________________________________________________________________ Does your child having any feeding issues? ☐No ☐Yes: ☐gagging ☐vomiting ☐ underweight

☐ overweight ☐ other ________________________________________________________________

What type of food does your child eat? ☐Formula ____________ ☐ pureed ☐ finely chopped ☐regular

Is constipation a problem? ☐No ☐Yes: _____________________________________________________

Has your child their hearing tested? ☐No ☐Yes Location: ___________________ Date _________

Has your child had their vision tested? ☐No ☐Yes Location: ____________________ Date ________ Does your child have any history of hospitalizations, surgeries, serious or chronic illness? ☐No ☐Yes:

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______________________________________________________________________________________ Does your child have any pain issues or concerns? ☐No ☐Yes: ________________________________ Does your child use corrective or adaptive equipment, such as glasses, leg braces, crutches, walkers or wheelchairs? ☐No ☐Yes: ______________________________________________________________

Medicines Please list all current medicines, supplements and homeopathic remedies you child is currently taking. Medicine Dose Prescribed to treat

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Therapy and Behavioral History Please list any therapists, counselors or agencies who have worked with your child. ☐None Service or Agency Location Dates

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Neurodevelopmental Family Questionnaire

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Did your child have any attachment or bonding difficulties before the age of 5? ☐No ☐Yes

If yes, please explain: _____________________________________________________________________

Does your child participate in any community activities, such as sports, clubs or religious groups?

☐No ☐Yes: __________________________________________________________________________

Do you have concerns with how your child plays or interacts with other children? ____________________

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What are your child’s favorite activities? _____________________________________________________

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What do you consider to be your child’s strengths? _____________________________________________

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What do you consider to be your child’s weaknesses? ___________________________________________

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Do you have concerns about your child’s behavior? ☐No ☐ Yes If yes, please describe: ___________

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School

Is your child currently enrolled in school? ☐No ☐Yes: ______________________________________

Grade________________________ School District ____________________________________________

Does your child have an IEP? ☐No ☐Yes

Child’s classroom: ☐General Education ☐General education with pull out ☐Self-contained classroom

Has the school voiced any behavioral or academic concerns? ☐No ☐Yes:

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Neurodevelopmental Family Questionnaire

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Development Please list your child’s developmental progress in the following areas:

Areas of Development

Compare your child’s development to other children their age. Please check the appropriate box

Comments Please note any deterioration or loss of skills:

Same as others

Slower Faster

Smile at parent

Play peekaboo

Point to show something

Make good eye contact

Sit alone

Crawl

Walk alone

Social skills (sharing, taking turns)

Self-control skills (impulse control, delaying gratification)

Make consonant sounds (for example: ba-ba)

Responds to name

Use simple command such as “no”

Speak 2 to 3 word phrases

Speak full sentences

Drink from cup

Eat with utensils

Understands object names

Obey verbal commands (“please come here”)

Get dressed by self

Ride 2 wheel bike with no training wheels

Daytime toilet trained (urine)

Daytime toilet trained (stool)

Nighttime toilet trained (urine)

Nighttime toilet trained (stool)

Cognitive skills (memory, comprehension, knowledge)

If your child is talking, is he or she easy to understand? ☐No ☐Yes: _____________________________ ______________________________________________________________________________________ If you child does not speak, how does he or she communicate? ____________________________________

Neurodevelopmental Family Questionnaire

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Family History: Family medical history is an important part of developing a plan of care for your child. Please indicate if anyone in your family has the following conditions:

Condition/Circumstance Child Mother Father Sibling Mother’s Family

Father’s Family

Intellectual disability

Learning disorder

ADHD/ADD

Seizures or epilepsy

Alcohol abuse

Drug abuse

Physical or emotional Abuse

Sexual abuse

Depression

Anxiety disorder or panic attacks

Schizophrenia

Visual disability or problems

Deaf or hard of Hearing

Tics or Tourette’s Syndrome

Chronic illness

Autism spectrum disorder

Genetic disorder

Special education services

Birth defects

Arrests or incarceration

Other:

Caregiver Name _________________________________________ Relationship ____________________ Occupation _____________________________________________ Age ___________________________

Caregiver Name _________________________________________ Relationship ____________________ Occupation _____________________________________________ Age ___________________________

Sibling Name Gender Age Lives with Child? ______________________________________________________________________________________

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Do any other individuals live with the child? ☐No ☐ Yes: ______________________________________ ______________________________________________________________________________________

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Do you have any religious or cultural beliefs that are important for us to know when providing care?

☐No ☐Yes: ___________________________________________________________________________ ______________________________________________________________________________________ Is there anything else that you would like us to know about your child? _____________________________

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I would like more information about:

☐Developmental Disabilities Administration ☐Social Security/ SSI ☐Counseling Resources (for child, sibling, family members) ☐Transition to Adult Care (guardianship, vocational training, independent living) ☐None of the above

Please fill out and mail at least 7 days before your child’s appointment. If you cannot send before, bring the completed form and records to your appointment.

Mail: Seattle Children’s Hospital, NDV Clinic PO Box 5371, OC.9.840 Seattle, WA 98145-5005

Fax: 206-987-3824 (Fax medical and school records to 206-985-3121)

Email: NDVNurses@seattlechildrens.org

E-mail communication is not secure and may be intercepted in transmission or misdirected. You may learn more about the risks of using e-mail at www.seattlechildrens.org/patients-families/partnering-with-us/email-risks-conditions/. When you communicate with members of your care team and include patient identifiable health information or other confidential information, you agree that you are aware of and assume these risks. If you discover that an email communication containing patient identifiable health information or other confidential information has been intercepted in transmission or misdirected, please report it to the Seattle Children’s privacy office at privacy.questions@seattlechildrens.org or by calling, toll free, 1-866-987-2000, extension 7-1200.

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Seattle Children’s offers interpreter services for Deaf, hard of hearing or non-English speaking patients, family members and legal representatives free of charge. Seattle Children’s will make this information available in alternate formats upon request. Call the Family Resource Center at 206-987-2201. This handout has been reviewed by clinical staff at Seattle Children’s. However, your child’s needs are unique. Before you act or rely upon this information, please talk with your child’s healthcare provider. © 2018 Seattle Children’s, Seattle, Washington. All rights reserved.

Neurodevelopmental