Carolinas Center for Cleft Lip & Palate Surgery Carolinas Center for Oral & Facial Surgery 8840 Blakeney Professional Drive Suite 300 Charlotte NC 28277 P: (704) 716-9840 F: (704) 716-9841 Patient Information Packet

Thank you for your interest in our center, we are pleased to have the opportunity to meet you and your child.

We request that you fill out the enclosed questionnaire and bring it to your appointment. Some of the questions may be difficult to answer or may not apply, but please complete it to the best of your ability. We ask these questions to find out your present concerns and the patient’s history. The questionnaire is read by the team members and contains important information that can help us provide the best care to meet the needs of our patients and their families. Please bring to your appointment:

1. This patient information packet 2. Insurance card(s) and photo ID

3. Any pertinent medical information/records

If you have questions, please call Abby at 704-716-9840.

You may also contact her by email at [email protected].

Carolinas Center for Cleft Lip & Palate Surgery Carolinas Center for Oral & Facial Surgery Patient Information Questionnaire

Patient Name: _______________________________________________________________ Date: _____________________________________________ Diagnosis: ____________________________________________________ Date of Birth: _______________________________ Gender: M F Home Address: ____________________________________________________________________________________________________________________ City: _________________________________ Patient’s Race:

Caucasian

State: __________________________________ County: _____________________________________

African American

Other: ______________________________

Was patient adopted?

YES

Interpreter needed for team visit?

NO

Asian

Native American

When? ______________________

YES

NO

Hispanic

From Where? ______________________________

For which language? ______________________________________

What are patient’s strengths? ___________________________________________________________________________________________________ What are patient’s challenges/issues? _________________________________________________________________________________________ Mother Name (first, middle, last )____________________________________ DOB: __________________________________________________ Address: ______________________________________________________ _________________________________________________________________ Email: _________________________________________________________ Phone: _______________________ (home), _______________________ (cell), _______________________ (work) Marital status: single married divorced Highest grade completed: __________________________________ Occupation: __________________________________________________ Work status: part-time full-time unemployed Custody: Physical Legal

Father Name(first, middle, last)____________________________________ DOB: __________________________________________________ Address: ______________________________________________________ _________________________________________________________________ Email: _________________________________________________________ Phone: _______________________ (home), _______________________ (cell), _______________________ (work) Marital status: single married divorced Highest grade completed: __________________________________ Occupation: __________________________________________________ Work status: part-time full-time unemployed Custody: Physical Legal

If patient lives with primary caregiver other than parent, please specify: Name(first, middle, last)____________________________________________ Relationship to patient: ____________________________________________ DOB: __________________________________________________ Address: _____________________________________________________________ ________________________________________________________________________ Email: ________________________________________________________________ Phone: _______________________ (home), _______________________ (cell), _______________________ (work) Marital status: single married divorced Highest grade completed: __________________________________________ Occupation: __________________________________________________________ Work status: part-time full-time unemployed Custody: Physical Legal

Other persons living in home with patient Relationship

Name

Sex

DOB

Highest grade completed:

Where does your family live? (check one) House

Location:

Apartment Rural

Condominium

In Town

Transportation to and from clinic: Is transportation a problem?

No

Auto

Yes

Trailer

Suburbs

County van

Shelter

Homeless

Other

Insurance Information:

Primary Insurance: _____________________________________________________________

Phone: ________________________________________

Policy Holder: ___________________________________ Relationship to Patient: __________________ Subscriber ID#_____________________

Send claims to (address): ____________________________________________________________________________________________________________

Secondary Insurance: _____________________________________________________________ Phone: ________________________________________

Policy Holder: ___________________________________ Relationship to Patient: __________________ Subscriber ID#_____________________

Send claims to (address): ____________________________________________________________________________________________________________

Please check any of the following resources your family receives: Social Security Disability

Women, Infant, Children (WIC)

Supplemental Security Income (SSI) Public Housing Assistance

Family History (please check all that apply):

CAP-C

Medicaid

Food Stamps

Health Choice

Tricare

Cleft lip

Cleft Palate

Speech Problems

Hearing Loss

Mental Retardation

Breathing Problems

Eating Problems

Blood Problems

Heart Problems (from birth) Sleeping Problems

Growth Problems

Congenitally Missing Teeth

Kidney Problems

Seizures

Syndromes (specify): ________________________________________________________________________________________________________________

Birth History: Please list all pregnancies mother has had: Year

Outcome (normal boy/girl, miscarriage, medical abortion, still birth, child with physical or mental problems)

Mother’s health during pregnancy and delivery (please describe if answer is not NO) Did mother receive prenatal care? YES NO SOME

Was birth control used prior to pregnancy? YES NO Type: Tobacco use? YES NO Type: Weeks gestation: Exposure to toxins? YES NO Describe

X-rays during pregnancy? YES NO

Medical issues during pregnancy? YES NO Rh negative? YES NO

Problems with labor/delivery? YES NO

Were prenatal vitamins taken? YES NO SOME Medications taken: Herbal supplements: Alcohol use? YES NO # drinks daily: 1 2-3 Illnesses? YES NO

>3

Describe

Amount of weight gain during pregnancy: ______lbs Baby’s gestational age: Baby’s birth weight: Apgar Scores:

Other information: _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________

Surgical/Medical History Hospitalizations/Surgeries: Hospital

Location

Dates

Reason for hospitalization

Serious illnesses not requiring hospitalization: Date

Describe illness

Dental/Orthodontic History (please describe if answer is not NO) How often does the patient visit dentist?

Has patient ever had braces? YES NO

How often does patient brush teeth?

Crooked teeth? YES NO

Does patient have tooth pain? YES NO Thumb/finger sucking habit? YES NO From age ____ to age _____

Dates:

Missing teeth? YES NO

Difficulty chewing due to teeth? YES NO

Ear, Nose, Throat History (please describe if answer is not NO) History of ear infections? YES NO

History of hearing loss? YES NO

PE Tubes? YES NO

Wears hearing aid(s)? YES NO

Medications?

Describe:

Date(s) placed:

Allergies?

Sleep apnea concerns? YES NO

Breathing problems? YES NO

Tracheostomy? YES NO

Speech, Language, and Communication (please describe if answer is not NO) Age started to babble (i.e., mamama): ______________

Age said first word: ___________________

Describe:

Does it sound like his/her nose is stuffy when speaking?

Mispronounces words? YES NO

Understands what others are saying well for age? YES NO

Does speech sound like it is coming through the nose? Expresses self well for age? YES NO

Concerns about speech?

Speech therapy? YES NO

Communicates effectively with other children? YES NO

Communicates wants and needs effectively to parents? YES NO Primary Language in Home:

At what age was child first exposed to English?

Dates:

Feeding History (please describe if answer is not NO) Infant fed by: (circle one) Pigeon bottle

Haberman Feeder

Mead Johnson bottle Regular bottle Other: _________________________

Age weaned from bottle: Breast

Feeding tube? Never____ From ages ____ to ____

Problems eating or picky eater? Describe:

YES NO

Educational History School

Location

Dates attended

Early Intervention/ CDSA Preschool Elementary School Middle/Junior High High School

Assessment and Intervention History Academic Area of Difficulty

Testing Date

Grade Level

Eligible for Services?

Services Provided with Dates

Sounding out words Reading Comprehension Math Spelling Written Expression Handwriting Attention problems Behavioral/Emotional functioning Speech clarity/quality Language

Social and Emotional Development (please describe if answer is not NO) Has one or more friends? YES NO

Has a good relationship with siblings? YES NO

Enjoys preschool/school? YES NO

Gets discouraged easily? YES NO

Activity level typical for age? YES NO Goes to sleep pretty quickly/sleeps through the night?

Can adapt to sudden changes in schedules and daily routines? YES NO Understands the feelings of other children and responds

YES NO

Tends to become worried before tests and classroom projects? YES NO Often appears sad? YES NO Is generally cooperative? YES NO

History of bullying and/or teasing by peers? YES NO Asks for help when he/she needs it? YES NO

appropriately to them? YES NO

Seems to worry a lot about his/her physical appearance? YES NO Can talk about his/her feelings? YES NO Has a good appetite most of the time? YES NO

Attends well in the school classroom and at home? YES NO Attention span typical for age? YES NO

Provider Information: Referring Physician: _____________________________________________________________ Phone: _______________________________________ Address: _________________________________________________________________________________________________________________ Primary Care Physician: ________________________________________________________ Phone: ______________________________________ Address: _________________________________________________________________________________________________________________ Dentist: ____________________________________________________________________________ Phone: ______________________________________ Address: _________________________________________________________________________________________________________________ Orthodontist: _____________________________________________________________________ Phone: ______________________________________ Address: _________________________________________________________________________________________________________________ Speech/Language: _______________________________________________________________ Phone: _______________________________________ Address: _________________________________________________________________________________________________________________ Other Provider: __________________________________________________________________ Phone: _______________________________________ Address: _________________________________________________________________________________________________________________ Has patient had a genetics evaluation? YES NO Date: _______________________ Location: _______________________________ Results: ___________________________________________________________________________________________________________________ (Please have these records sent Carolinas Center for Cleft Lip & Palate Surgery as soon as possible if a genetics evaluation was completed) Please list your questions/concerns that you would like addressed at your team visit: _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________

Part 2: School Questionnaire

Carolinas Center for Cleft Lip & Palate Surgery

Dear Teacher,

Carolinas Center for Oral & Facial Surgery 8840 Blakeney Professional Drive Suite 300 Charlotte NC 28277 P: (704) 716-9840 F: (704) 716-9841

_______________________________________________ will be seen our Cleft Lip & Palate Team in the near future. Please fax the following information to our center at (704) 716-9841 - Attention: Abby.

1). Current IEP (if applicable)

2). Current Psycho-Educational Testing, Speech-Language Testing, OT/PT Testing

3). Most recent Report Card

4). Your impressions of this student’s school performance in the following areas: Is this student performing at grade level in the following areas?

Yes

No

Decoding

Word Identification

Reading Comprehension Written Expression Handwriting

Math Calculation

Math Word Problems Clarity of Speech

Ability to Communicate with Others

Understanding of Classroom Instructions Social Interactions with Peers Other Concerns (describe):

Thank you so much for taking the time to get this information to us so we can provide the best care possible for this patient! If you have further concerns that you would like to discuss, please contact us at the above number. Sincerely,

Carolinas Center for Cleft Lip & Palate Surgery

Part 3: Release Authorization

Carolinas Center for Cleft Lip & Palate Surgery Carolinas Center for Oral & Facial Surgery 8840 Blakeney Professional Drive #300 Charlotte NC 28277

Date: ________________________________________ Name: ________________________________________ DOB: ________________________________________

AUTHROIZATION FOR RELEASE OF MEDICAL AND HEALTH RELATED INFORMATION

Parent(s) or Legal Guardian(s): ____________________________________________________________________________________________

Address: ______________________________________________________________________________________________________________________

I request Carolinas Center for Oral & Facial Surgery/Carolinas Center for Cleft Lip & Palate Surgery to release medical information on the above named patient to the persons or agencies listed below who are responsible for the care, treatment and/or education of the above named patient. I understand that the medical information release may include HIV (AIDS) test results and psychological evaluations as well as other sensitive information.

1. _________________________________________________________________________________________________ 2. _________________________________________________________________________________________________ 3. _________________________________________________________________________________________________ 4. _________________________________________________________________________________________________ 5. _________________________________________________________________________________________________ 6. _________________________________________________________________________________________________ 7. _________________________________________________________________________________________________ 8. _________________________________________________________________________________________________ 9. _________________________________________________________________________________________________ 10. _________________________________________________________________________________________________

I do NOT consent to the release of the following information: (If there are no exceptions to the release of information, write “none”). _________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________ In addition, I hereby authorize release of information to any other health care and education professionals recommended by members of Carolinas Center for Cleft Lip & Palate Surgery during the conference evaluation. Information MAY NOT be released to the following: _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ I understand that such released information is intended for the sole purpose of providing the best possible patient advice and care. Further, I understand that this permission shall remain in effect for one year from the date of the signature and that I may cancel this authorization at any time by submitting a written request to Carolinas Center for Cleft Lip & Palate Surgery. Signature: ___________________________________________________________________________________________________________________ Date Signed: Witness:

______/______/______

Relationship to Patient: ____________________________________________

___________________________________________________ Date:

______/______/______