*100077* Division of Neurology 807 Children’s Way Jacksonville, FL 32207 904-697-3780

Neurology New Patient Questionnaire **Attention we ask that all New Patients call our appointment confirmation line at 904-697-3826 one week prior to the visit to confirm ** Please bring this completed form with you to the first doctors’ visit In order to help us get to know your child and concerns better, please answer the following questions to the best of your ability. Child’s Name:

Date of Birth:

Medication Allergies (specific reaction)_____________________________________________________

Please describe briefly the problem(s) for which we are seeing your child: 1)

_____________________

2)

____________________ _____

Please list the main questions you would like us to answer: 1) 2)

_____________________ _____________________

Primary Care Physician

Name: ____________________________________ City ________________________

Name of past Neurologist, if any: ____________________________ City __________________________________ Who referred your child for this consultation? _________________________________________________________ Has your child ever had any of the below neurological studies: Date

Where was study done?

MRI

Yes / No

Normal / Abnormal

EEG

Yes / No

Normal / Abnormal

CT

Yes / No

Normal / Abnormal

Please list all current medications and doses this child is taking, including over-the-counter medications, vitamins, minerals or supplements. 1.

______

4.

2.

3.

_____

_____

5.____________________________ 6.___________________________________

Pregnancy & Birth History

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Childs Name______________________________________

DOB:____________________

Age of mother at delivery _____Number of prior pregnancies: Were any of the following a concern during pregnancy?  Febrile illnesses/fever  Trauma or accidents

 Abnormal bleeding  Cigarette use

 No problems/complications  High blood pressure  alcohol or substance use

List any medications/drugs taken by the mother 1)

2)

Where was this child born?

City and state

Birth weight:

Was infant born early or late ?

Method of Delivery:  Vaginal

 Cesarean Section

Did infant need/have any of the following?  Bilirubin lights for yellow jaundice

 Early labor  Diabetes  Concerns about baby’s movements in the womb 3)___________________

_____ Hospital

__________

(if so, how many weeks?)________

If by Cesarean section, why?

 CPR or resuscitation after birth

 Ventilator use  Antibiotics

 Special Care or Intensive care nursery

 Other ____________________________________

 Seizures

 Bleeding in brain  Surgery

At what age was child sent home from the nursery? ____________

Past Medical History 

Hospitalizations ___________________________________________________________________________________



Head Injury with loss of consciousness _________________________________________________________________



Serious Illness/Major Operations ______________________________________________________________________



Has your child ever seen a psychologist or psychiatrist before?

If yes, please list dates and reasons for visits: ________________

__ 

____________ Are your childs’ immunizations up to date?______________________________________________________________

Development Do you think the child has developed normally? If no, please explain ________________________________________________ Which hand does the child prefer?

 Right

 Left

 Both the same

Has the child received any therapy for developmental delays?

 Unsure

If yes, please explain ___________________________________

________________________________________________________________________________________________________ As best as you can recall, at what age did the child achieve these milestones? Rolled over Said ‘Mama/Dada’

Sat alone

Walked

Spoke in 2-word sentences

Rode tricycle Toilet trained

Family History Other than this child has anybody in the family had any of the following conditions:

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Drank from a cup

Childs Name______________________________________ Specify: M = Mother F= Father B= Brother S=Sister

DOB:____________________

A= Aunt U= Uncle GM =Grandmother

GF=Grandfather

C= First Cousin

 Epilepsy/Seizures

 Seizures with fever

 Fainting Spells

 Sudden Unexplained Death

 Breath Holding

 SIDS

 Learning Disability

 Mental Retardation

 ADD/ADHD

 Slow Development

 Deafness

 Birth Defects

 Cerebral Palsy

 Autism

 Migraines

 Other headaches

 Brain/Spinal Tumor

 Aneurysm

 Tics/Tourette

 Muscle/Nerve disorder

 Stroke/paralysis

 Psychiatric Disorder

 Other (specify) ___________________________________________________________________________________________

Social History Where does this child currently go to school or daycare? Has this child ever repeated a grade, if so, which?

What is the current grade level? Favorite Hobbies: _____________________________________

Does this child require a special classroom? Yes No. If yes, what type,  SLD  EH  EMH  TMH Does this child receive special services?  Physical Therapy  Occupational Therapy  Speech Has this child’s intelligence or development ever been tested?

Yes No

 Other ____________________

Other ________________________

Results ? _______________________________________

Who lives at home with the patient?_______________________________________________________________________________ Mother’s occupation? Parents are (circle correct choice)

Father’s occupation?  Married

 Not married

 Separated

 Divorced

Age of Brothers: ________________ Age of Sisters: __________________________

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Childs Name______________________________________

DOB:____________________

Review of Systems: Please indicate whether the following are problems for this child. Please check any that apply. Neurological: □ Normal □ Seizures (if yes, please see section below) □ Headaches (if yes, please see section below) □ Tremor □ Weakness □ Numbness Constitutional: □ Normal □ Weight loss □ Fatigue Allergy: □ Normal □ Immune problems Eyes: □ Double vision □ Change in vision

□

Normal

Ear, Nose and Throat: □ Normal □ Change in hearing □ Ringing in ears □ Vertigo/dizziness Cardiovascular: □ Normal □ High or Low blood pressure □ Irregular pulse (arrhythmias) □ Palpitations Respiratory: □ Normal □ Asthma □ Shortness of Breath □ Chronic cough Gastrointestinal: □ Normal □ Change in appetite □ Vomiting □ Diarrhea □ Constipation Genitourinary: □ Normal □ Kidney disease □ Incontinence □ Recurrent urinary tract infection Endocrine: □ Normal □ Thyroid disorders □ Diabetes or elevated blood sugar Skin: □ Normal □ Birthmarks Hematological: □ Normal □ Anemia Musculoskeletal: □ Normal □ Pain □ Arthritis Psychiatric/Behavioral: □ Normal □ Change in mood or depression □ Change in memory

□ □ □ □

Other/Details Fainting Snoring Change in coordination (gain/balance) Change in memory, speech, language or development

□

Unexplained fever

□

Other/Details Significant allergies other than medications

□ □

Eye pain Glasses

□ □

Severe or recurrent sinusitis Difficulty swallowing

□ □

Murmurs Congenital heart defects

□ □ □

Aspiration Recurrent pneumonia Apnea

□ □ □

Stool incontinence Abdominal pain Reflux

Other/Details

Other/Details

Other/Details

Other/Details

Other/Details

□

Other/Details Bed wetting Birth control pills Date of last menstrual period _______ Other/Details Low blood sugar

□

Unusual rash

□

Easy bleeding or bruising

□ □

Trauma/Injury Scoliosis

□ □

Sleep habits Change in school performance

□ □ □

Other/Details

 H. Abram  R. Bakerywala

Other/Details Other/Details

History form completed by: Name (Print) _________________ History form reviewed by:

Other/Details

Other/Details

Signature _____________

 D. Hammond

 R. Sheth

Date __________  Erick Viorritto

Signature _______________________ Date ____________________

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Childs Name______________________________________

DOB:____________________

Headache Section If your child is being seen for headaches, please complete the section below. 1.

How many full days of school were missed in the last three months due to headaches?________

Please complete the below headache assessment Score regarding your child’s headaches over the past 3 2. months: How many partial days of school were missed in the last three months due to headaches? ______ 1. 2 3. 4. 5. 6.

How many full days of school were missed due to headaches?________________________________________________ 3. How many days in the last three months did you function at less than half your ability in school because of a headache? _____ How many partial days of school were missed due to headaches? ____________________________________________ (do not include the number of days from the last two questions) How many days did you function at less than half your ability in school because of a headache? _____________________ (do not include the number of days from the last two questions) 4. How many days were you not able to do things at home (i.e. chores, homework, etc.) due to a headache?________________ How many days were you not able to do things at home (i.e. chores, homework, etc.) due to a headache?_____________ 5. How many days did you not participate in other activities (i.e. play, go out, sports, etc.) due to a headache?______________ How many days did you not participate in other activities (i.e. play, go out, sports, etc.) due to a headache?___________ 6. How many days did you participate in these activities, but function at less than half your ability?______________ (doyou notparticipate include days counted in 5th question above) How many days did in these activities, but function at less than half your ability?____________________ (do not include days counted in 5th question above) Total Score _________ Total Score ___________

Please describe a typical headache for your child. Include details about where the pain occurs, how long the headache lasts, frequency of headaches, what it feels like and any other helpful details about the headaches. Also, please note anything that provides relief during the headache – medications, sleep, etc.

______________________________________________________________________________________________________________________________________________________________________________

1. 2.

How many months or years has your child had headaches?

Less than 6 months

6-12 months

1-4 years

More than 4 years

During a typical severe headache, circle any of the below which your child might experience: Nausea Vomiting Avoidance of bright lights Avoidance of loud sounds Paralysis/weakness of an arm or leg Numbness/tingling of an arm or leg Confusion Stomach Pain Fever

Dizziness Avoidance of exercise Behavior changes Visual problems: -blurred vision -loss of vision -double vision -seeing stars -unusual flashes of light

3.

Are you able to identify any pattern to your child’s headaches such as special foods, hunger, lack of sleep, weather changes. Please describe.

4.

Is there anything that makes the headaches worse? Please describe.

5.

What makes your child feel better when she or he has a severe headache? ________________

6.

Do you have any concerns about your child being depressed or anxious? If yes, please describe

7.

Have there been any recent stresses or changes in your child/teen’s life recently, such as difficulties in

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____________

Childs Name______________________________________ school or at home?

DOB:____________________

If yes, please describe:

Seizure Section If your child is being seen for seizures, please complete the section below. Please describe a seizure for your child. If there is more than one type, please number and list them below.

1.

How often does the child have seizures? Daily

Weekly

Monthly

2.

What age did the seizures start? ______________________________________________________________________

3.

How long do the seizures usually last? __________________________________________________________________

4.

Has the child ever had a seizure that lasted longer than 30 minutes? __________________________________________

5.

Has the child ever had a seizure that required paramedics and/or an ambulance? ________________________________

6.

What is the longest seizure free period for the child?

7.

Is the child weak on one side after a seizure? ____________________________________________________________

8.

Does the child know when a seizure is coming on? ________________________________________________________

9.

Does one side of the body shake during a seizure? ________________________________________________________

______________________________________________________

10. Does anything specific seem to trigger the seizure? _______________________________________________________ List all medications that the child has taken for seizures and what side effects, if any, they have experienced.

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