How did you hear about our practice? Pediatrician referral Self referral (Internet/ Family/Friend) Other
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- Tamsyn Lawson
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1 New Patient: PEDIATRIC HEADACHE QUESTIONNAIRE Page 1 Please complete this questionnaire prior to your appointment. It will be used during the appt & become an part of the medical record. Teens should complete as much as they can independently. Patient Name Age Date of Birth Today s D ate Address Male Female Home ph Cell ph Work ph Pediatrician name How did you hear about our practice? Pediatrician referral Self referral (Internet/ Family/Friend) Other Please bring any and all reports of previous neurological testing, consultation that was done outside the University of Rochester/Golisano Children s Hospital health system. If the patient has ever had a brain CT, MRI please obtain a copy of the films for the neurologist to review and to add to the medical record. Please describe why you are bringing your child for evaluation today: 1. Previous Evaluations Type of Evaluation Check all that apply Neurologist Ear/Nose/Throat specialist Psychologist/Psychiatrist/Counselor Physical Therapy Massage Acupuncture /Chiropractor Relaxation / Biofeedback Herbal / Homeopathic medicine Other Approx. Date Provider Name/Location 2. Previous Testing Test Date Result Check all that apply Important!: Date of last dilated eye exam by Ophthalmologist MRI MRA / MRV Head CT Lumbar Puncture Sleep Study Sinus films Other?
2 3. Current Medications: Page2 Medication For what? (headache,adhd,asthma,etc) Pill size(mg) or concentration (mg/ml) Dose Times per Day 4. Was a diagnosis made for a certain type of headache?(if yes, what type & by who) 5. Has the patient been on daily Preventative Headache Medications in the past? NO (if YES, which ones? Please check all that apply) Elavil (Amitriptyline) Pamelor (Nortriptyline) Topamax(Topiramate) Inderal (Propranolol) Periactin (cyproheptidine) Depakote (Valproic acid) Neurontin (Gabapentine) Calan (Verapimil) Other 6. Abortive Medications: What medications have been used to treat headache pain? None Advil/Motrin (ibuprofen) Tylenol (acetaminophen) Aleve/Anaprox (Naproxen) Aspirin Benadryl(diphenhydramine) Compazine(prochlorperazine) Zofran (Ondansetron) Phenergan (promethazine) Indocin (Indomethacin) Imetrex (sumatriptan) Zomig (zolmitraptan) Maxalt (Rizatriptan a. About how many doses of pain reliever medications have you needed to use over the last 4 weeks? 7. Vitamins or Supplements: Have you used nutritional supplements to manage the headaches? NO Magnesium Vitamin B2 (Riboflavin) Petadolex (Butterbur) Feverfew Melatonin Co Q10 Other 8. Emergency Room Care: have you ever been treated in a hospital Emergency Room for your headaches? No Yes (where & when was the last time?) 9. Have you ever been hospitalized for headache (overnight)? No Yes 10. Past Medical History a. Any problems during pregnancy/delivery of this child? NO Yes b. Infancy: Birth Weight lbs oz Born premature? NO Yes - How much? wks premature c. Were there health problems during infancy? NO Yes what kind? d. List illnesses during childhood for this child e.development: Were there any problems with development? (Not sitting, walking, talking, etc as expected) NO Yes what kind? Was/Is Early Intervention Services involved? NO Yes - circle all that apply OT / PT / Speech Any Hospitalizations or Surgeries? Date Age Illness / Surgery Hospital ROS: Has this child ever had any of the following problems? General health: Missed a significant amount of school due to headaches Head: Concussion/Head injury history Abnormal head size (too large / too small) Eyes: Wears corrective lenses Double vision Other (describe) Vision changes with headaches (circle all that apply): Blurry -Glare - Flashing lights - Zigzag lines- Tunnel vision Other eye conditions: Ears / Nose / Throat: Hearing problems Recurrent sinus infections Recurrent strep throat
3 Other Ear/Nose/Throat conditions Page 3 Skin: Eczema Acne Patches of brown/red/pale skin Significant birthmarks (dark or light patches of skin) Heart: Murmur Skipped beats/arrhythmias Heart defect High/Low Blood Pressure Other cardiac condition Breathing: Asthma Recurrent sinus Infections Snoring Pauses in breathing during sleep Other respiratory condition Digestive: Recurrent episodes of nausea/vomiting with headaches Cyclic vomiting Gastric Reflux Recurrent stomach pain Other digestive concerns Muscles /Bones /Joints: Numbness/tingling w/ headaches Episodes of muscle weakness w/ headache (one-sided or both sides?) Other skeletal conditions Hormonal/ Endocrine/ Bleeding: Thyroid problems -Low / High Growing too slow Easy bleeding/bruising Eating disorder Frequent bloody noses Diabetes Obesity Sudden weight loss Other hormone or blood-related conditions? : ADOLESCENT GIRLS: Age of onset of menstrual periods yrs Are periods regular? Yes No Has the patient ever been on birth control pills or Depo shots? No Yes Did headaches worsen or improve after beginning these medications? Are you on this medicine now? Yes No Neurologic : Has the child had any history of the following conditions? Head trauma Brain infections Seizures Staring spells Stroke ADHD Anxiety Depression Motion/Car sickness Learning difficulties Tics Fainting spells Dizziness Fainting spells/syncope Patches of brown/red/pale skin Low or High muscle tone Autism Tremor Numbness Other neurologic condition/details regarding any of the above conditions: Concussion History: Has your child ever been diagnosed with concussion? NO Yes How many times? At what age/s? Was there ever loss of consciousness with a concussion injury? NO Yes We will go over these concussions in detail during the appointment. Please be prepared to supply details of each concussion occurrence, testing & follow up done. Counseling / Psychiatric: Has your child ever been seen by a counselor, psychologist or psychiatrist? No Yes Name of provider Original concerns: -Was the experience beneficial? Yes No -Is your child still being seen this provider Yes No -Have you, as a parent, or a health care provider ever been concerned about the patient in regards to any of the following symptoms or conditions? Anxiety Worry Depression Suicide ideation Extreme shyness Sleeplessness Obsessive Compulsive Oppositional Defiant Disorder Conduct Disorder Substance abuse Cutting Bipolar ADHD Eating disorder In trouble at School or with the Law Other psychological concerns
4 11. Social History & Habits: Page 4 a. Who lives in the same house as the patient? If 2 households, list everyone in each household. Name Age Relationship to Patient b. Is this child adopted? No Yes at what age? Foster Child c. Are both parents involved in this child s daily life? Yes NO (WHO IS NOT INVOLVED? Mom / Dad ) d. Any of these changes in child s life (in the last 1-2 yrs)? Parent separation Move Custody change Family members leaving the home Significant illness/death e. Other stressors at home? f. Mother s occupation: Father s occupation: 12. SCHOOL : School Name Current Grade Address School Nurse Phone Number Fax# Special Services at school (please circle): OT PT Speech Special Ed IEP 504 Plan Class Size (Please circle): Regular 15:1:1 12:1:1 8:1:1 Homeschooled Other Has your child had psychoeducational or neuropsychological testing? If yes, when & where? What was the outcome of the testing? How many days of school have been missed the most recent school year specifically related to headache? full days missed Part days/in late Sent home ill with headache Is your child currently participating fully in their usual gym class and sports? Yes No Please explain: How have grades been since the headaches began or increased in frequency? Unchanged/Typical for this child Worsened Improved Failing Most recent grades have been : (circle all that apply) A / B / C / D / F 13. Family Medical History: Please check the box if ANY family members have any of the following conditions and list the person s relationship to the patient next to the problem. Migraines ADHD Headaches of any type Tic s/tourette s Motion sickness Syncope/Fainting Seizures Degenerative disease Developmental Delay Mental retardation Learning disabilities Brain Tumors Autism Stroke Early death (before age 35) Bleeding/Clotting disorder Anxiety Depression Bipolar Schizophrenia OCD ODD/Conduct Disorder Form Completed by Relation to patient Date completed
5 HEADACHE DIARY Name Date of Birth / / Date Time Headache Began What was going on when headache began? (in class, sleeping..) Any Warning Signs that headache was coming on soon? Part of Head with Pain (forehead, left side ) Type of Pain (squeezing, throbbing, pressure ) Intensity of Pain (circle the number that best describes pain: 0=No pain 10= extremely severe) Other Symptoms (nausea, vomiting, sensitive to light, numbness ) Treatment (Medication or other things done to lessen the pain or make headache go away) How did the headache affect usual routine? (went home from schoo l early, stayed in class anyway, missed event ) Hours of Sleep the Night Before the Headache Meals missed the day of headache? Anything exciting or stressful? (Tests, arguments, party ) How long did the headache last? What helped the most?
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New Patient Questionnaire. Today s Date: Date of Birth: Name: Home Address: City: State: Zip: Home Phone: Work Phone: address: Referred by:
Pamela A. Pappas MD, MD(H) Classical Homeopathy for Mind, Body, and Soul 8114 E. Cactus Rd., Suite #240 Scottsdale, Arizona 85260 Phone: 480.656.9218 Fax: 602.626.3695 E-mail drpam@drpampappas.com New
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Address City State Zip. Home Phone Cell Work. (For SHPT use only) Emergency Contact Phone
Somerset Hills Physical Therapy, PC 180 Mount Airy Road, Suite 103 Basking Ridge, NJ 07920 Phone (908) 766-1407 Fax (908) 953-8454 wwwsomersethillsptcom Patient Information: Name Sex M F Date of Birth
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Ohio Psychotropic Medication Quality Improvement Collaborative. Minds Matter. Toolkit. for You and Your Family. This is the property of
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Sound View Acupuncture and Chinese Herbs 5410 California Ave SW, #202, Seattle, WA
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Pediatric Intake Form (6-12 years) Age: Date of Birth: / / Gender (circle one): female or male
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The information you provide us will greatly help us provide the highest quality and most comprehensive care for you.
Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Riley Sleep Evaluation Questionnaire
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us better understand your child and his or her sleep problems. Shade circles like t like
Diana Quinn, ND Integrative Healthcare Providers 3053 Miller Rd Ann Arbor, MI P (734) F (734) New Patient Intake Form
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MEDICAL ASSESSMENT PART 1 - SOCIAL HISTORY
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Aspire Pain Medical Center
Aspire Pain Medical Center Welcome to Aspire Pain Medical Center. We are looking forward to providing you with the best care to manage your needs. Please take the time to complete the following questionnaire
DEPARTMENT OF MEDICINE Outpatient Intake Form
NAME: Last First Middle Initial Date of Birth: ADDRESS: HOME PHONE: WORK PHONE: Did someone refer you here? Yes No If yes, please give name: Main reason for your visit today: MEDICAL HISTORY: (Please check