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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 LurieCenter@partners.org or mail the completed form to our address listed above. Once we receive and review the completed Patient Information Form, we will mail you appointment information or refer you to another provider(s) that may better serve your needs. This process can take up to three weeks.
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:Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421
Phone 781.860.1700/Fax 781.860.1766Page 1 of 14 Form Version March 2019
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)
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 2 of 14 Form Version March 2019
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 Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421
Phone 781.860.1700/Fax 781.860.1766Page 3 of 14 Form Version March 2019
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
If yes, please specify:
Depression during pregnancy? Yes No
Other medical problems during pregnancy? Yes No
If yes, please explain:
Any concerns about fetal health during pregnancy? Yes No
If yes, please explain:
Were this child’s movements different than in other pregnancies? NA Yes No
If yes, please explain:
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 4 of 14 Form Version March 2019
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
If yes, please specify:
Apgar scores, if known: 1min 5min
Did mother have complications? Yes No
If yes, please specify:
Section 4. Newborn History
Birth weight: Birth city:
Was baby in the special care nursery? Yes No
If yes, please specify:
Was the newborn physical exam normal? Yes No
If yes, please specify:
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:
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 5 of 14 Form Version March 2019
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
If yes, please specify:
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
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 6 of 14 Form Version March 2019
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?
If yes, please specify:
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?
normal overly sensitive under sensitive other, please explain:
Is your child sensitive to taste?
normal overly sensitive under sensitive other, please explain:
Is your child sensitive to sight?
normal overly sensitive under sensitive other, please explain:
Is your child sensitive to being touched?
normal overly sensitive under sensitive other, please explain:
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
If yes, please explain:
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 Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421
Phone 781.860.1700/Fax 781.860.1766Page 7 of 14 Form Version March 2019
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
If yes, please explain:
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
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 8 of 14 Form Version March 2019
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
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 9 of 14 Form Version March 2019
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
If yes, please list:
Does your child have any special dietary restrictions? Yes No
If yes, please list:
Is your child taking any vitamins and supplements? Yes No
If yes, please list:
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 10 of 14 Form Version March 2019
Please list all current and past medications and their dosages:
Medication Dose Current Past
Does your child have any medication allergies? Yes No
If yes, please list:
Does your child have any side effects to medications? Yes No
If yes, please list:
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
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 11 of 14 Form Version March 2019
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.
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 12 of 14 Form Version March 2019
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
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 13 of 14 Form Version March 2019
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 this form:
o For all patients age 4 and under, an office note from the Pediatrician 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:
LurieCenter@partners.org
Or mail to:New Appointments
Lurie Center1 Maguire Road
Lexington, Massachusetts 02421If 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 luriecenter@partners.org.
Lurie Center for Autism/1 Maguire Road, Lexington, MA 02421 Phone 781.860.1700/Fax 781.860.1766
Page 14 of 14 Form Version March 2019
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