Autoimmune Encephalopathy Clinic Intake Form

Transcription

1 Autoimmune Encephalopathy Clinic Intake Form TODAY S DATE: / / _ PATIENT INFORMATION Child s Name (last, first, middle) Birth date: Sex: Parent/Guardian: Relationship to child 1: 2: Street Address: Apartment/Suite: Home phone no.: ( ) City: State: ZIP Code: Alt. phone no.: ( ) CURRENT PHYSICIANS e.g., neurologist, psychiatrist, psychologist, counselor, immunologist Primary Care Physician: Location(address): Phone no.: Fax no.: Consultant 1: Location(address): Phone no.: Fax no.: Consultant 2: Location(address): Phone no.: Fax no.: Consultant 3: Location(address): Phone no.: Fax no.: Consultant 4: Location(address): Phone no.: Fax no.: Has your child been diagnosed with PANS/PANDAS by another physician? (If yes please specify): No Yes Specify What other diagnoses has your child received? Hospi /length of stay): Patient History Did your child meet all early childhood developmental milestones? No Yes If no, please specify: How would you describe your child's health prior to his/her first episode?

2 Please check all symptoms that were problematic during childhood (before onset of CPAE): Anxiety(fears/phobias, separation anxiety) OCD(previously diagnosed by professional) Behavioral problems/behavioral Regression Learning disorder/academic problems in school Attention deficits/trouble paying attention Fine motor difficulties or delay Gross motor difficulties or delay speech difficulty or delay Progressive developmental delay Restrictive eating/food refusal Dilated/big pupils Nightmares Paranoid thoughts Delusions/Paranoid thoughts Oppositional/defiant behaviors Post-traumatic stress disorder Auditory processing issues Self harming behaviors Hyperactivity/Impulsivity Tics/movement disorder Mood swings/moodiness Problems with violence Hallucinations/psychosis Suicidal ideation Stuttering Seizures Sleep issues Mania Low muscle tone Intrusive thoughts Depression/sadness Obsessions Irritability Compulsions Autism spectrum Social skills issues Visual apraxia Hoarding IQ < 70 None of the above Sensory issues/bothered by smells, sounds, textures, or lights Body-focused repetitive disorders (skin picking, nail biting, hair pulling) : Discrete Neuropsychiatric Deteriorations We are seeing your child in our clinic for a sudden neuropsychiatric deterioration/episode (characterized by symptoms such as OCD, eating restriction, anxiety, tics, hallucinations, delusions, hyperactivity, etc. See Definitions below). Some children have several of these episodes starting from early childhood. We would like to understand all of your child's episodes and preceding illnesses (if known). Neuropsychiatric Symptoms (Definitions for Parents) Obsessions: are unwanted thoughts or images that come in to your child's head. They can be scary or embarrassing or strange. Some children have thoughts of bad things happening to their parents, or of getting sick. Some children have trouble getting the thoughts out of their head. Contamination Obsessions: Excessive concern with dirt, germs, illnesses, bodily waste, environmental contaminants, animals, insects, household cleaners. Etc. Aggressive Obsessions: Fear of harming self and/or others or that harm will come to self and/or others; acting on unwanted impulses; fear of responsibility for terrible outcomes; violent imagery; blurting out obscenities or insults; stealing things, etc Sexual Obsessions: Perverse sexual thoughts, images, impulses; aggressive sexual behavior towards others, etc. Hoarding / Saving Obsessions: Fear of losing things, etc. Magical Thoughts / Superstitious Obsessions: Lucky / unlucky numbers, colors, words, etc. Somatic ObsessionsExcessive concern with illness / disease, body part or aspect of appearance, etc. Religious Obsessions: Excessive concern or fear of offending religious objects, moral behavior, etc. Miscellaneous Obsessions: Need to know / remember; fear of saying / not saying certain things or the right things; intrusive images, sounds, words, music, numbers, etc. Compulsions: are routines, rituals, or actions that your child might feel like he/she has to do in order to stop bad things from happening or until something is 'just so'. Examples of compulsions include lining things up or arranging things in a certain way, or ask their parents for reassurance. Washing / Cleaning Compulsions: Excessive hand washing, showering, grooming, cleaning; measures to prevent contact with contaminants, etc. Checking Compulsions: Checking locks, toys, books, did not / will not harm others or self, etc. Repeating Rituals: Rereading, erasing, rewriting; repeating activities, in / out of doorways, up / down from chair, etc. Counting Compulsions: Counting objects, numbers, words, etc. Ordering / Arranging: Need for symmetry, evening up items, etc.

3 Hoarding / Saving Compulsions: Difficulty throwing items away; concern with objects of monetary or sentimental value, etc. Excessive Games / Superstitious Behaviors: Touching an object or self a certain number of times to avoid bad things happening, etc. Rituals Involving Persons: Need to involve another person in rituals, etc. Miscellaneous Compulsions: Need to tell, ask, confess; ritualized eating behaviors; need to touch, tap, rub; hair-pulling; self-damaging or self-mutilating behaviors; list making; measures (not checking) to prevent harm to self / others, terrible consequences, etc. Mood swings: is when your child's mood changes quickly and frequently. He/she may go from being happy or calm to being upset about something. Suicidal ideation/behavior: is when your child thinks or expresses not wanting to be alive anymore, or does something intentionally to hurt himself/herself. An example of suicidal ideation is when a child says that he/she wants to die or would rather be dead. Irritability: is when your child is easily annoyed or bothered by little things that would not normally upset someone. Aggressive behavior: can cause physical or emotional harm to others. Examples of aggressive behavior include yelling, hitting/kicking, getting into fights, and bullying others. Behavioral/developmental regression: is when children act younger than they are. They might start using baby talk again, or play games or act a way they did when they were younger. Delusions/Paranoid thoughts: Delusions are beliefs that are clearly false. A child with delusions may be convinced that the belief is true even when presented with evidence to the contrary. Paranoid thoughts are a type of delusion that involves intense, excessive, and unfounded fears. Urinary frequency: are when your child has increased need to use the bathroom, in frequency or urgency. Enuresis: wetting pants during the day or night Sensory amplification: increased sensitivity to sound, light, noise, smell, taste, or touch Hallucinations: are when your child hears or sees things that are not there in a way that seems strange. Some children hear voices or they see people or things when no one is there. Motor tics: are sudden jerks or movements, such as forceful eye blinking or a rapid head jerk to one side or the other. Some tics might be more subtle, like scrunching the nose. They occur during otherwise normal behavior. examples of motor tics include jerking the head or arms or legs, or stretching the mouth or jaw in a way that seems odd or too frequent. Vocal tics: are sudden utterance of sounds such as throat clearing, sniffling, or words. They can be very loud or soft. examples of vocal tics are repeated words or noises, or coughing. Characterization of Neuropsychiatric Episodes We are now going to ask you about discrete episodes of symptom escalation that your child has had. (There will be a separate section to discuss baseline (longstanding) issues). We will ask you to describe each episode. Please use your calendar or your child's medical records to put this timeline together. Starting from early childhood, how many discrete episodes of neuropsychiatric symptoms has your child experienced, including current episode: Comments:

4 Initial Episode Onset of Symptoms: How would you describe the onset? Hyperacute (time from no/minimal symptoms to maximum symptoms is less than or equal to 72 hours Acute (time from no/minimal symptoms to maximum symptoms is greater than 3 days or less than or equal to 1 week) Sub-acute (time from no/minimal symptoms to maximum symptoms is greater than 1 week, but less than 8 weeks) Insidious onset (time from no/minimal symptoms to maximum symptoms is greater than 8 weeks, difficult to pinpoint when symptoms started) Not sure Approximately how long did the initial episode last? 1 day Few days Few weeks Few months 3-6 months 6-9 months Did your child have any of the following immediately preceding the initial epsiode? Check all features of preceding conditions/illnesses associated with Episode 1: Fevers Joint pains and/or muscle pains Upper respiratory illness Sinus infection Ear ache Intestinal illness Face pain Strep throat Headache Nasal discharge Sore throat Fatigue/tired Ear infection Rash Skin infection Prolonged coughing illness Urinary tract infection (UTI) Lyme disease Pneumonia Flu-like illness Scarlet Fever Dental infection Loose tooth Dental cleaning tooth disruption/event Vaccine Menses None of the above Not sure (please specify): **If you selected rash or vaccine above, please describe and specify: Was there an identified cause of the episode?

5 Please list any residual symptoms after the initial Episode: Not Present Present Not sure Obsessions (e.g., fear of germs, lack of symmetry) Compulsions (e.g., hand-washing, arranging things) Food refusal/avoidance Urge to overeat; thinking about eating all the time Fluid refusal/avoidance Anxiety (fear/phobias, separation anxiety) Mood swings/moodiness Emotional liability (inappropriate crying/laughing spells) Suicidal ideation/behavior Depression/sadness Irritability Aggressive behaviors Oppositional behaviors Hyperactivity or impulsitivity Trouble paying attention Poor self-care (dressing, bathing, brushing teeth, etc) Immature judgment for age Baby talk behavior/developmental regression Worsening of school performance Worsening of handwriting/copying/art Cognitive symptoms (difficulty thinking, foggy brain, memory problems) Daytime fatigue Waking unrefreshed Pain (headaches, abdominal pain, body pain) Sleep disturbances Daytime wetting or bed-wetting (enuresis) Urinary frequency (uses restroom frequently) Bothered by sounds, smells, textures, or lights (sensory amplicfication) Hallucinations Delusions or paranoid thoughts Change in personality Dilated/big pupils Tics (movements) Tics (sounds) Please describe "other" behavioral/developmental regression: Comments on episode 2: How many subsequent episodes has your child had (since the initial episode)? more than 5 If your child has had multiple episodes, how would you describe the course of the child's illness?: Episodic with return to normal Episodic not returning to normal Not episodic Unsure Is your child currently experiencing symptoms? Yes No

6 Please list any medications your child is currently taking: Medication Check if applicable Dosage Frequency Duration Start Date Antibitioic (penicillin, azithromycin, etc) NSAID (naproxen, ibuprofen, etc) Steroid (prednisone) IVIG Still Taking? Helpful? (Yes, No, Unsure) Psychiatric Medications Please list any therapies you have tried with your child: Therapies Tried Attempted? Dates (approximate) Behavioral Therapy (ABA) Mental Health Counseling Occupational Therapy Speech Therapy Please list any procedures your child has had done: Procedure Check if Complete Date Completed MRI EEG Sleep Study

7 Records to Send (Optional): Please send the results of recent lab work, examples of your child's handwriting/artwork prior to episode vs current, and/or a brief narrative of your child's illness by the PCP or other physician. ***PLEASE DO NOT SEND EXTENSIVE MEDICAL RECORDS*** What would you consider your child's most distressing symptoms from your point of view or your child's point of view? IS there other information you would like to share with our team members regarding your child's illness? What would you like to accomplish at your visit with the team?