awakenings medical center new patient...

Awakenings Medical Center New Patient Paperwork

PATIENT INFORMATIONPatient Name:

Mother's Name:

Father's Name:

Patient Date of Birth:

Gender: Male Female

Siblings (names and ages):

Street Address:

City, State Zip:

Country (If other than USA):

Home Phone (Area code first):

Mother's Cell Phone (Area code first):

Father's Cell Phone (Area code first):

Mother's Work Phone (Area code first):

Father's Work Phone (Area code first):

Preferred Fax:

Preferred Email:

Patient's Primary Care Physician:

Primary Care Physician's Address/Phone/Fax:

Preferred Local Pharmacy Name/Phone/Fax:

Do you have a preferred local compounding pharmacy? If so provide

Name/Phone/Fax:

Emergency Contact Name:

Relationship to Patient:

Address:

Phone:

PRIVACY CONSTRAINTS (Choose One) : No Constraints-OK to leave messages, send mail and e-mail

Restrictions-person to person communication with patient/guardian only

Other: 540 Charter Blvd. Suite 100, Macon, GA 31210 Phone 478-471-0089 ext. 111www.awakeningsmedicalcenter.com Fax 478-471-0708

[email protected]

INSURANCE INFORMATION (while we do not participate in any insurance "networks" and fees are due in full at the time of your visit, our electronic medical record is able to create a universal claim form for you to file if you wish)Policy Holder's Name:

Policy Holder's Date of Birth:

Policy Holder's Relationship to Patient:

Insurance Company's Name:

Claims Address (on back of card):

ID Number:

Group Number:

Employer Name as Listed on Policy: In the sections that follow, we are trying to familiarize ourselves with your child. Please be as descriptive as possible.

PREGNANCY AND DELIVERY1) Anything unusual about the pregnancy? (Illnesses, medications, antibiotics,

difficulty):

2) Full Term

Premature

How many weeks gestation?

3) Mother's Blood Type:

4) Child's Blood Type, if known:

5) During pregnancy, was mother given:

a. Rhogam (shot for Rh negative blood type)

b. Flu Shot

6) Did mother take any medications during pregnancy?

7) Cigarette smoking or alcohol intake during pregnancy?

8) Miscarriages?

9) Labor and Delivery Duration:

10) Delivery Method (Choose One): Vaginal

Induced C-Section Why:

11) Group B Strep:

12) Antibiotics at Delivery?

540 Charter Blvd. Suite 100, Macon, GA 31210 Phone 478-471-0089 ext. 111www.awakeningsmedicalcenter.com Fax 478-471-0708

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13) Anything unusual about the delivery?

14) APGAR Score if remembered:

15) Anything unusual about the baby's hospital stay or initial newborn period? (Jaundice,

respiratory problems, infections, poor feeding, etc)

INFANCY1) Any problems in early infancy? (Unusually quiet or overactive, unusually stiff or

floppy, feeding problems, reflux, constipation, etc)

2) Breast feeding (describe the length and character of feeding effort):

3) Colic or milk intolerance (describe symptoms if present):

4) Formula used:

5) When was food introduced?

MEDICAL HISTORY

1) What diagnoses does your child have?a. Autism b. ADHD c. Anxiety d. Depression e. Learning Disability f. Sensory Integration or Sensory Processing Disorder g. Language Delay h. Verbal Apraxia i. Other (Please Specify):

2) Date of last routine Physical Exam: a. Any problems identified?

3) Are you child’s immunizations up to date? Yes Noa. Any adverse reactions? (if yes, please describe):

4) Has your child had:a. Hearing screening or Audiology Evaluation? Yes No

i. If yes, date, location, results, and any concerns: b. Vision Screening or Ophthalmology Evaluation? Yes No

i. If yes, date, location, results, and any concerns:

5) Any recurring illnesses?

6) Frequent need for antibiotics?


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7) Frequency of and age at first ear infections:

8) Asthma or allergies? If yes please describe:

9) Accidents or trauma? If yes please describe:

10) Hospitalizations/Surgeries? If yes list dates as well as illness/procedures:

11) Any specialists your child has seen and their impressions:

12) Is your child currently on any routine medication? If so, please list below along

with the prescribing physician:

13) Any medical evaluation for the cause of your child’s behavioral, developmental, or

medical symptoms? (Blood tests, genetic testing, EEG, brain MRI, etc):

Please bring copies of blood and urine tests and copies of reports from any medical evaluations if

available.

DIET HISTORY1) Does your child have a good appetite?

2) Is your child a picky eater? If yes, what age did picky eating start?

3) Does your child have unusual food preferences or dislikes? Any food cravings?

4) Do any foods seem to make your child’s behavior better or worse?

5) Have you tried any diets to see if they affect your child’s behavior (e.g. casein free,

gluten free, etc)? If so, when were they done and were they helpful?

6) Is your child currently taking any vitamins or nutritional supplements? If so, please

list names of supplements, doses and frequency, and the reason your child is taking

it.

7) Does your child eat a lot of (if yes, please list what foods, and how often your child

consumes them):

a. Milk Products

b. Carbohydrates or wheat containing products

8) What is a typical meal for your child:

a. Breakfast:

b. Lunch:

c. Snack:


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d. Dinner:

9) What types of the following foods does your child eat?

a. Protein

b. Fruits

c. Vegetables

DEVELOPMENT1) Age at which you suspected something was unusual? Please describe what you felt

was different:

2) What age do you think your child acts like, in terms of development and learning?

3) Did your child ever lose spoken words? If so please describe the speech regression:

4) Did your child lose social and/or motor skills? If so please describe:

5) Did you associate any regression with a vaccine, illness, or other event? If so please

describe:

6) What are your main concerns with your child/s development?

7) What are your child’s developmental strengths?

8) Has your child had any previous evaluations of his or her learning? If yes, please

indicate the type of the evaluation, date, and general results. Please bring any

reports of previous evaluations or testing with you to your first appointment for us

to scan into their chart. If your child has had numerous evaluations, please bring

copies of the most recent.

Please indicate at what age your child achieved the following skills: (Do not worry if

you cannot remember any or all of these milestones, their importance can be

determined during our discussion at the first appointment). If they have not achieved

a certain milestone, please indicate as well.

1) Language Skills:a. Social Smile (smiled in response to you) b. Laughed c. Babbled


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d. Said “mama,” “dada” e. Understood “no” f. Pointed to communicate g. Said first word h. Spoke in “gibberish” i. Waved bye-bye j. Played “peek-a-boo” or “pat-a-cake” k. Followed a one-step instruction l. Pointed to pictures m. Identified body parts n. Combined two words o. Had a 50-word vocabulary p. Spoke in short (at least three word) sentences q. Used pronouns (e.g. I, me, you) correctly r. Able to state a full name s. Able to state age t. Identified basic colors

If your child is non-verbal or has limited language:a. How does your child communicate with you? (e.g. to lead you to desired

objects/food/activities, etc) b. Does your child respond to their name? c. Is your child able to indicate yes/no (with words or by head nod/shake)?

2) Gross Motor Skills:a. Rolled Over b. Sat alone c. Crawled d. Pulled to standing e. Cruised around furniture f. Walked independently g. Walked up steps h. Pedaled tricycle i. Rode bicycle

i. With training wheels ii. Without training wheels


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j. Skipped 3) Fine Motor/Adaptive Skills:

a. Picked small objects with a pincer (thumb-forefinger grasp) b. Scribbled with crayon c. Fed self with fingers d. Used spoon e. Used fork f. Drank from a cup g. Toilet-trained h. Dry at night i. Undressed self completely j. Dressed self completely k. Tied shoes l. Able to put shoes on correct feet

BEHAVIORAL CONCERNS1) Main behavioral concerns:

2) What are your child’s behavioral strengths?

3) Primary goals:

4) Has your child ever had evaluations of their behavior? If yes, please indicate the

type of the evaluation, date, and general results. Please bring any reports of

previous evaluations or testing with you to your first appointment for us to scan into

their chart.

5) Has your child ever received any formal interventions regarding their behavioral

difficulties, such as counseling/therapy, medication, etc?

6) Is your child currently receiving therapy?

7) Is your child currently on any medications for behavior? If yes, please list

medications, dosages and frequency, and name of prescribing physician.

Does your child exhibit any of the following?

Yes No …Tantrums

Yes No … Aggression

Yes No … Fleeing from tasks/people

Yes No … Self-injurious behavior

Yes No … Ritualistic routines


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Yes No … Mouthing

Yes No … Spitting

Yes No … Transition difficulties

Yes No … Self-stimulatory behaviors (visual, tactile, verbal, physical, etc)

Yes No … Echolalia

Yes No … Inattention

Yes No … Hyperactivity

Yes No … Impulsivity

Yes No … Distractibility

Yes No … Significant variability in behavior from day to day

Yes No … Destructiveness

Yes No … Oppositional Behavior

Yes No … Lying

Yes No … Stealing

Yes No … Bed Wetting

Yes No … Difficulty getting along with siblings or peers

Yes No … Trouble making friends

Yes No … Depressed mood

Yes No … Mood swings

Yes No … Low self-esteem

Yes No … Anxiety/Nervousness

Yes No … Nail biting

Yes No … Thumb sucking

Yes No … Obsessions

Yes No … Compulsions

Yes No … Sleep Problems

Yes No … Withdrawn behavior

Yes No … Preference to play alone

Yes No … Poor eye contact

Yes No … Lack of make-believe play

If yes, please explain:


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EDUCATIONAL HISTORY1) Do you have any concerns about your child’s learning or school placement?

2) What is your child’s current:

a. School

b. Grade

c. Type of classroom (mainstream, special education, etc)

3) Has your child ever repeated a grade?

4) Has your child ever had formal testing regarding their learning (such as

psychological testing, educational testing, speech/language evaluation)? If yes,

please bring reports of previous testing or evaluations to the first appointment for

us to scan into your child’s chart.

5) Is your child receiving any of the following special services at school or outside of

school (if yes, please list where therapy is received, and frequency of therapy):

a. Speech Therapy:

b. Occupational Therapy:

c. ABA Therapy:

d. Floor Time:

e. Relationship Development Intervention (RDI):

f. Feeding Therapy:

g. Physical Therapy:

h. Other (please specify):

6) What are your child’s best subjects in school?

7) What are your child’s most difficult subjects in school?

8) How do you think your child learns best?

a. Visual learner

b. Auditory learner

c. Kinesthetic (“hands on”) learner

CURRENT STATUS1) Major food cravings:

2) List all foods your child consumes:


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3) Does your child eat or mouth non food items? If so please describe:

4) Potty trained? If yes, at what age?

5) Describe your child’s stools-color, smell, consistency (liquid, mashed potatoes, rocks,

etc.) shape, (balls, snakes, etc.) frequency, blood, mucus or whole food present,

sink/float:

6) Does your child have bloating/pass excessive gas/unusual belching/stomach

ache/unusual behaviors associated with bowel movements?

7) Does your child cover their ears or show auditory defensive behavior?

8) How does your child handle crowded places?

9) Does your child like certain kinds of touch and/or dislike others? Describe:

10) Does your child have sensitivity to food textures or difficulty swallowing?

11) Is cutting hair, nail cutting or brushing teeth difficult?

12) Does your child have sensitivity to texture of certain clothing or tags?

13) Does your child have any OCD (obsessive/compulsive) type behaviors (lining things

up, rigid rituals, "stuck" on an object)?

14) Does your child have difficulty with transition from one activity or setting to another?

Please describe:

15) Does your child have any self-stimulatory behaviors (toe walking, hand flapping,

spinning themselves or objects, etc.)?

16) Does your child have any perseverating activities?

17) Do you have any sensorial concerns (tactile defensive, visual tracing, etc.)? 18) Does your child display any inappropriate behaviors (spitting, biting, hair pulling,

kicking, hitting, pinching, pants down, etc.)? 19) Are there any known reinforcers for your child?

20) Does your child have any specific dislikes or aversions?

21) How does your child interact with children who are the same age as they are?

22) How does your child interact with children who are older or younger than they

are?

23) How does your child interact with adults?

24) Does your child head bang/nail bite/self-mutilate/bite their arms or hands/skin pick?

If so, describe: 540 Charter Blvd. Suite 100, Macon, GA 31210 Phone 478-471-0089 ext. 111www.awakeningsmedicalcenter.com Fax 478-471-0708

[email protected]

25) Is your child moody, irritable, difficulty focusing, impulsive, overactive, anxious,

fearful, or aggressive? Please describe:

26) Does your child have processing problems (auditory, visual, motor, etc.)?

27) Does your child have fine motor difficulties, difficulty with buttons/zippers,

clumsiness, and/or gross motor skill troubles, etc.?

28) Does your child have language and/or signs? Describe:

29) Describe sleep from birth to present- briefly. Currently how long to fall asleep, do

they stay asleep, awakening time, naps:

30) With what daily activities do you have to help your child? (Dressing, bathing,

brushing teeth, eating):

31) What therapies is your child involved with currently? Please also list how often they

receive therapy.

32) What therapies have you tried in the past?

33) What type of school/educational program is your child enrolled in currently?

34) What medications and nutritional supplements is your child taking currently? (list

name, dose, and frequency):

35) What medications and nutritional supplements have helped the most?

36) What medications and supplements have a negative effect?

37) What aspects of your child’s current status concern you most?

38) What are your goals for your child’s medical care? List them in order of importance:

39) Is there anything else we should know about your child or your family?

REVIEW OF SYSTEMS (if present, please indicate if not described above)1) Breath holding, seizures, headache:

2) Fatigue/flushing/ dark circles under eyes/weakness/stiffness:

3) Cold hands/feet, cold/heat intolerance/ tingling of hands or feet/ cracking or peeling of

hands or feet:

4) Recurrent/chronic fever, recurrent illness/infection:

5) Blinking/ tics/ ringing in ears:

6) Bad breath/ nose bleeds/swollen gums/ dry lips or mouth:


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7) Acute sense of smell/ hearing:

8) Night blindness in child/family:

9) Geographic tongue:

10) Dermatographism (you can “write” on their skin with your fingernail and leave a

transient red mark):

11) Hoarseness/ sore throats:

12) Grinding teeth:

13) Anal itching or itchy skin or itchy scalp:

14) Eczema/ psoriasis/hives/acne/seborrhea (cradle cap)/ sensitivity to bug bites/ other

rashes:

15) Easy bruising/ dry skin/ pale skin/ oily skin:

16) Thickening of nails, ridging or splitting of nails, brittle or soft nails:

17) Strategies to put pressure on abdomen, reflux, colic:

18) Does your child lean on people or objects, do they lay down to play?

FAMILY HISTORY In this section, we are looking for genetic tendencies. If your child is adopted, please complete to the best of your knowledge, information about the biologic parents. Please consider, for each person, the following: asthma, allergies, diabetes, blood pressure problems, strokes or heart attacks when young (40’s and 50’s), blood clotting troubles (deep venous thromboses, pulmonary emboli, abnormal menstrual cycles), kidney disease, seizures, migraines, and other neurologic disorders, mental disorders (diagnosed, and “Uncle Louie was a little nutty”, especially schizophrenia, bipolar disease, depression, anxiety), substance use/abuse, hormone problems (most commonly thyroid troubles), autoimmune diseases (Lupus, rheumatoid arthritis, chronic fatigue, multiple sclerosis, etc.), night vision disturbance, gut troubles (Celiac, Crohn’s, constipation, irritable bowel, etc), learning disabilities, ADHD, etc:

1) Mother’s date of birth and medical history:

2) Father’s date of birth and medical history:

3) Siblings- names and dates of birth and medical history:

4) Maternal grandmother year of birth and medical history:

5) Maternal grandfather year of birth and medical history:

6) Paternal grandmother year of birth and medical history:

7) Paternal grandfather year of birth and medical history:

8) Any maternal siblings and significant medical history:

9) Any paternal siblings and significant medical history:


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10) Any of your child’s cousins with significant medical history:

SOCIAL HISTORY1) Mother’s education:

2) Mother’s occupation:

3) Father’s education:

4) Father’s occupation:

5) Who lives in the house?

6) Are parents:

a. Married

b. Separated

c. Divorced

d. Other:

7) Who would your child call their family?

8) Who are your child’s caregivers?

9) Do you have family nearby?

10) What is your support system for treatment and care of your child?

11) Do you have pets? If so, what kind, and how does your child do with them?

12) Does anyone smoke at home?

13) Any recent social stressors (deaths/losses, moves, changes in family situation, etc)?

ENVIRONMENTAL HISTORY1) Location of home (city/suburban/wooded/farm/etc):

2) Water source for home (well/city/filtration system and type if present):

3) Heating/Cooling system type (electric/gas/oil/other):

4) Do you live near power lines/woods/industrial area/water?

5) If you live near water, please describe (swamp, river, ocean, retention pond, etc.):

6) Does your home, and especially your child’s room, have a lot of

dust/mold/feathers/stuffed animals? Please describe:


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awakenings medical center new patient...

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