The 14 th International Fragile X Conference, Garden Grove, CA, Friday, July 18 th, 2014
|
|
|
- Lydia Richard
- 5 years ago
- Views:
Transcription
1 Presenters: Sharon Kidd, MPH, PhD; Ave Lachiewicz, MD; Deborah Barbouth, MD; Robin Blitz, MD; Carol Delahunty, MD; Dianne McBrien, MD; Elizabeth Berry-Kravis, MD, PhD The 14 th International Fragile X Conference, Garden Grove, CA, Friday, July 18 th, 2014 *The information presented today is part of a larger paper titled Fragile X Syndrome: A Review of Associated Medical Problems, which will be published in the journal Pediatrics in November of 2014
2 INTRODUCTION Individuals with fragile X syndrome (FXS) may be seen for a variety of medical problems related to FXS including seizures, recurrent ear infections and gastrointestinal disturbances. Need to know how big an impact medical problems in FXS have, so that physicians will diagnose and treat these problems earlier, to improve the long-term outcome and quality of life of patients with FXS. Awareness may help prevent and/or decrease certain behavioral problems, and may also provide clues to the diagnosis of FXS leading to testing
3 METHODS FOR REVIEW OF THE DATA The medical problems under review were chosen both because they are considered hallmark or typical medical problems for FXS and also would be commonly seen in general pediatric practice Review of previous data from published studies All papers that could be identified from PubMed searching of key words related to FXS and medical problems were included Comparisons were made by gender and to typically developing populations where possible to demonstrate differences between groups
4 METHODS FOR REVIEW OF THE DATA (CONTINUED) The FXCRC Database (CDC-funded database through middle of 2011) Nine fragile X specialty clinics from the FXCRC contributed data: 260 individuals (198 males and 62 females) with FXS Age of subjects ranged from birth to 55 years (average of 11 years old) 87.7% of parents reported their children as Caucasian and 6.5% as Hispanic. Questionnaires on a wide variety of medical, behavioral, and other concerns. All medical conditions were assessed by medical history and physical exam. This database is similar to the CDC-funded FORWARD Database which is currently collecting data from families of individuals with FXS since 2012
5 CARDIAC DISORDERS Review of the data: Mitral Valve Prolapse FXS Males FXS Females FXS All TYP FXCRC 0.5% 1.7% 0.8% n/a Other Studies n/a n/a 55% 0.7% Common questions: What is mitral valve prolapse? Why should I be concerned about this condition? Does my child with fragile X syndrome need to see a cardiologist (or heart specialist)?
6 CARDIAC DISORDERS Recommended treatment and follow-up: No evidence currently supports the routine cardiac evaluation of children and young adults with fragile X syndrome. Mitral valve prolapse, long thought to be associated with fragile X syndrome, does not appear to occur more frequently in FXS Children with a normal cardiac exam who have no cardiac symptoms (i.e. fainting, dizziness, recurrent fatigue) should not need to be referred to a cardiologist.
7 Review of the data: EAR, NOSE, AND THROAT DISORDERS Recurrent Otitis Media FXS Males FXS Females FXS All TYP FXCRC 54.7% 45.8% 52.6% n/a Other Studies 45-63% n/a n/a 12.6% Common questions: Why is this a problem in FXS? What are the symptoms associated with otitis media (ear infections)? Why is it a problem to have recurrent otitis media?
8 EAR, NOSE, AND THROAT DISORDERS Recommended treatment and follow-up: Children who are non-verbal or have developmental delay may not be able to communicate problems They may present with behavioral problems, sleep disturbances, irritability, change in appetite. Recurrent otitis media may lead to hearing loss and further problems with language and speech. Parents should consider an evaluation by an Ear, Nose, and Throat (ENT) specialist for a hearing test and possible PE tube placement for drainage of fluid.
9 Review of the data: GASTROINTESTINAL (GI) DISORDERS Gastrointestinal Problems FXS Males FXS Females FXS All TYP FXCRC Loose stools: 12.0% Loose stools: 7.0% Loose stools: 10.8% n/a Gastroesophageal Reflux: 10.5% Gastroesophageal Reflux: 13.6% Gastroesophageal Reflux: 11.2% Other Studies (general GI) 31.8% 27.8% 30.6% % Common questions: Why does my child have loose BMs? What is gastroesophageal reflux? Does something hurt - in irritable child?
10 GASTROINTESTINAL (GI) DISORDERS Recommended treatment and follow-up: Implement a healthy diet with high fiber and limit juice to 4 oz or less per day. Consider if lactose intolerance could be part of the problem. Discuss possible sources of pain with PCP (including Gastroesophageal Reflux Disease or GERD).
11 NEUROLOGICAL DISORDERS Review of the data: Seizures FXS Males FXS Females FXS All TYP FXCRC 12.1% 3.2% 10.0% n/a Other Studies % 4.8-7% 12-16% 1.2%* Motor tics *Epilepsy or other seizure disorder FXCRC 5.4% 6.7% 5.7% n/a Other Studies 19% n/a 15.0% 4.2% Motor and vocal tics Common questions: How likely is a patient with FXS to have a seizure? What should be done if a patient is having spells that might be seizures? Should an abnormal EEG be treated if there are no clear clinical seizures? Do seizures cause autism or more brain damage in patients with fragile X syndrome? Are hand flapping and other repetitive movements types of seizures or tics?
12 NEUROLOGICAL DISORDERS Recommended guidance, treatment, follow-up: Risk: Males with FXS in the FXCRC study had about a 12% chance of having a seizure This percent is lower than what was found in prior large studies because these were often conducted in clinics with neurology specialists and the FXCRC population is likely a less biased (toward seizures) population of individuals with FXS than would be seen by a neurology specialist EEGs (or electro-encephalograms): Patients having spells that might be seizures should have an EEG, usually an ambulatory EEG during which the spells can actually be captured on the EEG There is no evidence that treating patients that have abnormal EEGs when they don t have clinical seizures is beneficial; many patients, including those with FXS, have an abnormal EEG and never have a seizure
13 Recommended guidance, treatment, follow-up (cont d): Anticonvulsants: NEUROLOGICAL DISORDERS If patients are found to have seizures, they should be treated with anticonvulsants least likely to worsen behavior or cognition, until 2 years seizure-free Seizures in FXS are usually easily treated with one anticonvulsant patients with very difficult to control seizures are unusual and may have a secondary genetic influence increasing their seizure susceptibility the large majority of patients will grow out of their seizures before reaching adulthood
14 NEUROLOGICAL DISORDERS Recommended guidance, treatment, follow-up (cont d) Autism in seizures: There is a growing body of evidence that seizures are more common in individuals with FXS AND autism Seizures probably do not cause autism but there are likely common brain wiring problems and genetic influences that make a person more likely to have both seizures and autism only prolonged uncontrolled seizures in which the patient does not get enough oxygen are thought to cause brain damage Tics vs sterotypies: Hand flapping and other repetitive motor movements are not usually tics or seizures, they are motor stereotypies true tics are uncommon in FXS and in studies noting a high percentage of tics, there is probably confusion between tics and stereotypies
15 OCULAR DISORDERS Review of the data: Strabismus FXS Males FXS Females FXS All TYP FXCRC 17.5% 12.9% 16.4% n/a Other Studies % n/a n/a 2.6-4% Common questions: What are the implications of strabismus? What other eye problems might children with FXS have? What should parents do about eye and vision problems?
16 OCULAR DISORDERS Recommended treatment and follow-up: Strabismus can lead to amblyopia, which is secondary vision loss due to the failure of binocular fusion this eventually leads to suppression of the visual image from the discordant eye. Children with FXS have a higher prevalence of refractive errors including hyperopia, myopia, and astigmatism. Children with FXS may be difficult to evaluate due to developmental delays, attention problems, anxiety, and sensory processing problems. Regular evaluation by an ophthalmologist or optometrist who has patience and experience working with children with special needs is critical.
17 Review of the data: Sleep Problems SLEEP PROBLEMS Common questions: How frequent are sleep problems in children with FXS? What type of sleep problems can they have? How common are obstructive sleep apneas? What type of treatments are available? FXS Males FXS Females FXS All TYP FXCRC 26.0% 29.8% 26.9% n/a Other Studies n/a n/a 32-47% 10-25% Obstructive Sleep Apnea FXCRC 7.2% 7.1% 7.2% n/a Other Studies n/a n/a 34% 1.2% * Why is important to diagnose and treat the sleep disturbances? * Moderate sleep- disordered breathing
18 SLEEP PROBLEMS Recommended treatment and follow-up: Previous data show that up to half of children with FXS have some sleep problem, but our data suggest that the prevalence is lower. Sleep problems include: difficulty with falling asleep, walking up at night, sleep walking or sleep terrors, and obstructive sleep apneas. Your doctor should inquire about potential sleep problems at every well child visit. Symptoms such as snoring and pauses in breathing (or apnea) during the night are suggestive of OSA (obstructive sleep apnea) This is observed in up to one third of children with FSX.
19 SLEEP PROBLEMS Recommended treatment and follow-up (cont.): Sleep may also be affected by environmental, health and emotional factors which should be addressed and treated. Depending on the severity of the sleep problems, it may require behavioral or/and medical treatment or a referral to a sleep specialist. Children, especially those with ID, require adequate sleep for optimal development, learning, and functioning. Monitoring and managing OSA and other sleep problems are of particular importance in FXS, due to their relationship to poor daytime performance and behavior.
20 GROWTH
21 GROWTH CONT D
22 Common questions: GROWTH CONT D Do individuals with fragile X have normal growth? Males with fragile X have normal to slightly above average growth through childhood but tend to be slightly shorter after about age 10 yrs. Do individuals with fragile X have normal weight? Based on these growth curves, males with fragile X weigh somewhat more than average through age 20. Do boys with fragile X have an average birth weight? Yes, and they are born at the average gestational age Do they have average head circumferences? Head circumferences tend to be somewhat above average after birth.
23 GROWTH CONT D Common questions: Are there data on the females? There was very limited information on females. The limited information on females suggested that heights and weights were somewhat above average between eight and fourteen years. Recommended treatment and follow-up: Based on this information we primarily recommend that weight be carefully monitored. We recommend good diets and exercise programs.
24 What is a Medical home? THE MEDICAL HOME FOR CHILDREN WITH FRAGILE X An approach to provide comprehensive and coordinated primary care to optimize outcomes for children with special healthcare needs A pediatric team to deliver accessible, continuous, comprehensive, family-centered, coordinated, culturally effective care to children and their families What is the goal of a medical home? To ensure the child's medical, developmental, and behavioral needs are being met How does this paper help? Provide information to your child s pediatrician to increase their knowledge and support their ability to provide a more comprehensive medical home to your child with FXS
25 Medical Problem MANAGEMENT AND FOLLOW-UP OF MEDICAL PROBLEMS IN FXS Otitis Media Since children with FXS frequently have expressive language delays, it is important that all otitis media and/or any otologic issues be treated promptly and appropriately. Hearing testing may be considered if there is concern about a child s hearing. Gastrointestinal Problems If a child with FXS who also has symptoms suggestive of GER, such as frequent vomiting, feeding difficulties and failure to thrive, particularly if they also have hypotonia and oromotor problems, should be referred for appropriate medical evaluation and management. If a child presents with unexplained irritability or poor growth, then diagnosis of FXS should be considered. Evaluation and treatment for loose BMs or constipation would be similar to that for a child without FXS.
26 MANAGEMENT AND FOLLOW-UP OF MEDICAL PROBLEMS IN FXS (CONT.) Medical Problem Seizures For concerns about episodes that might be seizures, an electroencephalogram (EEG) evaluation should be obtained along with neurology referral. Ambulatory EEG can be used to distinguish behavioral spells from seizures. Special attention should be given to children with FXS and ASD, since they seem to be particularly at risk for epilepsy. Typically, patients would be treated after two documented seizures with anticonvulsants that are least likely to cause sedation or behavioral aggravation A view to discontinuation of treatment after an individual with FXS is seizure-free for two years.
27 MANAGEMENT AND FOLLOW-UP OF MEDICAL PROBLEMS IN FXS (CONT.) Medical Problem Ocular Disorders As strabismus and other ocular disorders, such as refractive errors, are common in children with FXS, pediatricians should monitor these conditions and refer children during the first 3 years for evaluation by a pediatric ophthalmologist or optometrist. This should be followed by yearly eye exams to continue to monitor for refractive errors. Sleep Problems The primary care physician should inquire about potential sleep problems in children with FXS at every well child visit. Depending on the severity of the sleep problems, it may require behavioral or/and medical treatment or a referral to a sleep specialist. Sleep may also be affected by other environmental, health and emotional factors which should be addressed and treated accordingly.
28 MANAGEMENT AND FOLLOW-UP OF MEDICAL PROBLEMS IN FXS (CONT.) Medical Problem Growth Problems The growth findings from the FXCRC Database suggest that patients with FXS may be at an increased risk for being overweight and for having somewhat diminished height in adulthood. We encourage healthy diets for our patients and good exercise programs to minimize problems associated with increased weight. Cardiac Disorders No evidence currently supports the routine cardiac evaluation of children and young adults with fragile X syndrome. Children with a normal cardiac exam who have no cardiac symptoms do not need to be referred to a cardiologist.
29 ACKNOWLEDGEMENTS We would like to thank the FXCRC and the National Fragile X Foundation for their work in bringing specialty clinics together to make work like this possible. Importantly, the FXCRC Database could only exist given the effort of parents of, and, children who have FXS. Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
30
Developmental-Behavioral Pediatrics Questionnaire for New Patients
Developmental-Behavioral Pediatrics Questionnaire for New Patients Date: Name of person completing questionnaire: Relationship to child: Email: IDENTIFYING INFORMATION: Information Child Name Child Birthdate
Health Care Information for Families of Children with Down Syndrome
Health Care Information for Families of Children with Down Syndrome American Academy of Pediatrics Introduction Down syndrome is a common condition caused by having extra copies of genes on the 21st chromosome.
Health Care Information for Families of Children with Down Syndrome
American Academy of Pediatrics Introduction Down syndrome is a common condition caused by having extra copies of genes on the 21st chromosome. Those extra genes change development during pregnancy, and
Health Care Information for Families of Children with Down Syndrome American Academy of Pediatrics
Syndrome American Academy of Pediatrics Introduction Down syndrome is a common condition caused by having extra copies of genes on the 21st chromosome. Those extra genes change development during pregnancy,
RETT SYNDROME AND SLEEP
2015 A good night s sleep promotes learning, improved mood, general good health, and a better quality of life for both your child and the whole family. This article written for Rettsyndrome.org by Dr Daniel
Medical Advisory Council: Verified
What is White Sutton Syndrome? White Sutton Syndrome (WHSUS) is a condition characterized by autism and developmental delay and/or intellectual disability, as well as a characteristic facial profile. Children
PEDIATRIC MEDICAL HISTORY QUESTIONNAIRE
Division of Otolaryngology Main Phone: 847 504-3300 Main Fax: 847 504-3305 Mihir Bhayani, MD Judy L. Chen, MD Mark E. Gerber, MD, FACS, FAAP Joseph Raviv, MD Ilana Seligman, MD, FACS, FAAP Michael J. Shinners,
Beacon Assessment Center Developmental Questionnaire Please complete prior to your first appointment
Beacon Assessment Center Developmental Questionnaire Please complete prior to your first appointment If you would prefer to complete the electronic version of this questionnaire on the Beacon Assessment
Pediatric Sleep Questionnaire
Pediatric Sleep Questionnaire Date Child's Name: Age Gender DOB Referring Physician: Primary Care Physician: Please answer fill out the following questionnaire regarding your child's sleep: What are your
Beacon Assessment Center
Beacon Assessment Center Developmental Questionnaire Please complete prior to your first appointment Contact Information: Client Name: DOB: Dates of Evaluation: Age: Grade: Gender: Language(s) spoken in
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 Not
Consensus of the Fragile X Clinical & Research Consortium on Clinical Practices Physical Problems in Fragile X Syndrome
Consensus of the Fragile X Clinical & Research Consortium on Clinical Practices First Issued: June 2011 Updated: October 2012 1 P a g e Introduction Fragile X syndrome (FXS) is a medical disorder caused
Autism: Practical Tips for Family Physicians
Autism: Practical Tips for Family Physicians Keyvan Hadad, MD, MHSc, FRCPC Alberta College of Family Physicians 61st Annual Scientific Assembly March 5, 2016 No conflict of interest Diagnosis and Misdiagnosis
New Patient Information Form
New Patient Information Form Patient Identification Prenatal Alcohol & Drug Exposure Clinic FASD CLINIC Patient s OHIP N. Female Male Race Patient s Name Birth Date Age First Middle Last Patient s Address
34th St. and Civic Center Blvd, Philadelphia, PA 19104, phone
34th St. and Civic Center Blvd, Philadelphia, PA 19104, phone 215-590-3630 www.chop.edu/gastroenterology Please complete this form prior to your child s visit. Please fax to (215) 590-7224 or e-mail it
EAC-AZ Webinar #7 November 18 th & 25 th. Today s Objectives 11/17/2015. Month 4 Related Medical/Behavioral Issues
EAC-AZ Webinar #7 November 18 th & 25 th Robin Blitz, MD Sara Bode, MD Amber Wright, CPNP Today s Objectives Month 4 Article Review STAT Reliability Testing ADOS Interpretation AzEIP / School Testing M-CHAT-R
Evergreen Speech & Hearing Clinic, Inc. Transforming Lives Through Improved Communication Since 1979
Patient Information Form Patient Information Patient Name: Date of Birth: / / Age: Last First MI mo day year Gender: Email Address: Address: City: State: Zip Code: Cell Phone: Home Phone: Work Phone: Referred
Vanderbilt University Autonomic Dysfunction Center Autonomic Dysfunction Questionnaire
Vanderbilt University Autonomic Dysfunction Center Autonomic Dysfunction Questionnaire Name: Date: Address: Phone number:( ) E-mail address: Birth date: / / Age: Sex: M F Height Weight Ethnic group: a.
The Long-Term Outcomes of Infants with Neonatal Abstinence Syndrome
Neonatal Nursing Education Brief: The Long-Term Outcomes of Infants with Neonatal Abstinence Syndrome https://www.seattlechildrens.org/healthcareprofessionals/education/continuing-medical-nursing-education/neonatalnursing-education-briefs/
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / /
PULMONARY CARE OF CENTRAL FLORIDA, P.A. Date: / / Patient Name Age DOB: / / Family Physician Referring Physician Telephone Number Telephone Number Pharmacy: Phone: Fax: MEDICAL HISTORY 1. What is your
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
Sleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
New Patient Questionnaire Pediatric Orthopaedic Surgery
Page 1 of 5 New Patient Questionnaire Pediatric Orthopaedic Surgery First Name: Last Name: Middle: DOB: Height: Weight: Primary Care Physician/Pediatrician Name: Address: Phone Number: Chief Compliant
Osher Center for Integrative Medicine Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician:
Pediatric Intake Form Name: Date: Date of Birth: Age: Current Pediatrician: How did you hear about us? What are your goals for this visit? Where would you like to see improvement in your child s health?
Evaluation of Failure to Thrive in a Young Child: Case Example of Jeff. Andrew Hsi, MD, MPH Family Medicine Pediatric Grand Rounds, 8 August 2012
Evaluation of Failure to Thrive in a Young Child: Case Example of Jeff Andrew Hsi, MD, MPH Family Medicine Pediatric Grand Rounds, 8 August 2012 Objectives for Presentation At the end of this talk; the
Guidelines for the Care of Children and Adolescents with a Seizure Disorder
Guidelines for the Care of Children and Adolescents with a Seizure Disorder Basic Team The special care needs of children with a seizure disorder can be met by an experienced primary care physician working
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Autism or Something Else? Knowing the Difference
Autism or Something Else? Knowing the Difference SUSAN BUTTROSS, M.D., FAAP PROFESSOR OF PEDIATRICS CENTER FOR THE ADVANCEMENT OF YOUTH UNIVERSITY OF MISSISSIPPI MEDICAL CENTER JACKSON, MISSISSIPPI Disclosure
Medical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best
Center for Pediatric Sleep Disorders New Patient Questionnaire
Center for Pediatric Sleep Disorders New Patient Questionnaire Date: Child s Name: DOB: Ethnicity: Caucasian American Indian Alaskan Native African American Asian Hispanic Polynesian Other Why is your
Autism and Gastrointestinal Problems (Part 2) Science Brief 3
Autism and Gastrointestinal Problems (Part 2) Science Brief 3 Evaluation, Diagnosis, and Treatment of Gastrointestinal Disorders in Individuals with ASD: A Consensus Report, Pediatrics, January 2010. Research
SLEEP EVALUATION QUESTIONNAIRE
Specialty Care Center SLEEP PROGRAM Patient Questionnaire ------------------------------------------------------------------------------------------------------------------------------------------ SLEEP
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)
PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this
Preferred phone: Best time to call you: Morning Afternoon Evening
Page 1 of 7 Address: City: State: Zip: County: Email address: Phone Number: (Home) (Work) (Cell) Preferred phone: Best time to call you: Morning Afternoon Evening CONTACT INFORMATION Patients over 18 years
Behavioral Interventions for Sleep Disturbances. By Matthew Osborne, M.S., BCBA
Behavioral Interventions for Sleep Disturbances By Matthew Osborne, M.S., BCBA Kahoot! Access conference Wi-Fi Direct your phone s internet browser to: kahoot.it Enter game PIN Disclosure I am NOT a sleep
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
Evergreen Speech & Hearing Clinic, Inc. Transforming Lives Through Improved Communication Since 1979
Audiology Hearing Testing VRA VNG/VEMP OAE BAER/ECochG Hearing Aids Cochlear/Bone Implants Tinnitus CAPD EHDDI Speech-Language Pathology Language Voice Accent Modification Autism Evaluation & Treatment
Evergreen Speech & Hearing Clinic, Inc. Transforming Lives Through Improved Communication Since 1979
Patient Information Form Patient Information Patient Name: Date of Birth: / / Age: Last First MI mo day year Gender: Email Address: Address: City: State: Zip Code: Cell Phone: Home Phone: Work Phone: Referred
*521634* Sleep History Questionnaire. Name of primary care doctor:
*521634* Today s Date: Sleep History Questionnaire Appointment Date: Please answer the following questions before coming to your appointment. Please arrive 15 minutes early with this packet filled out.
Patient Information. Legal Name: First Middle Last. Street City State Zip
Patient Information Legal Name: Home Address: First Middle Last Street City State Zip Gender: (circle one) Male Female Date of Birth: Social Security #: - - mm / dd / yyyy Email: Marital Status: Primary
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Centre for Clinical Practice SCOPE
NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE Centre for Clinical Practice 1 Guideline title SCOPE Autism: the management and support of children and young people on the autism spectrum 1.1 Short
BEHAVIOR & ADHD SCREENING INTAKE FORM
3171 N.E. Carnegie Drive, Suite A Lee s Summit, MO 64064 P: (816) 525-2800 F: (816) 525-4077 www.summitdoctors.com BEHAVIOR & ADHD SCREENING INTAKE FORM PATIENT NAME: TODAYS DATE / / LAST FIRST MI DATE
Western Health Specialist Clinics Access & Referral Guidelines
Western Health Specialist Clinics Access & Referral Guidelines Paediatric Medicine Clinics at Western Health: Western Health operates the following Specialist Clinic services for patients who require assessment
3855 Burton Street SE Suite A, Grand Rapids, MI Phone Fax Patient Information. Address: City: State: Zip:
3855 Burton Street SE Suite A, Grand Rapids, MI 49546 Phone 616.323.3102 Fax 616.323.3061 Patient Information Patient Name: Preferred Language: Address: City: State: Zip: Home Phone: Cell Phone: Cell Carrier:
Autism Spectrum Disorder What is it? Robin K. Blitz, MD Resident Autism Diagnostic Clinic Lecture Series #1
Autism Spectrum Disorder What is it? Robin K. Blitz, MD Resident Autism Diagnostic Clinic Lecture Series #1 Learning Objectives What can we talk about in 20 minutes? What is Autism? What are the Autism
PEDIATRIC SLEEP EVALUATION
PEDIATRIC SLEEP EVALUATION Directions: Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S INFORMATION
Autism Spectrum Disorder What is it?
Autism Spectrum Disorder What is it? Robin K. Blitz, MD Resident Autism Diagnostic Clinic Lecture Series #1 Learning Objectives What can we talk about in 20 minutes? What is Autism? What are the Autism
Pre-Admission Testing Questionnaire
Pre-Admission Testing Questionnaire Approximately 2 weeks prior to your surgery date you will receive a telephone call from our Pre-Admission Testing department. During this conversation, a Registered
Patient Adult Information History
Patient Adult Information History Patient name: Age: Date: What is the main reason for today s evaluation? Infant History Birth delivery: Normal C-section Delayed Epidural Premature: No Yes If yes, how
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
History Taking 3rd year Lecture. Thembi Katangwe 1st March 2011
History Taking 3rd year Lecture Thembi Katangwe 1st March 2011 Objectives To understand that the parent / guardian is the historian Build a rapport with parent/guardian as well as older children To understand
Pediatric Residency Child Neurology Elective
Pediatric Residency Child Neurology Elective Faculty: Stephen Deputy, MD Ann Tilton, MD Maria Weimer, MD Joaquin Wong, MD Shannon McGuire, MD Monica Pedersen, APRN, CPNP Goals: Over the past several years,
Sleep Evaluation Questionnaire
Directions Sleep Evaluation Questionnaire Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S
PLAS/RECON SURGERY PATIENT HEALTH HISTORY
PLAS/RECON SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications?
DEVELOPMENTAL BEHAVIOURAL REFERRAL
Date DEVELOPMENTAL BEHAVIOURAL REFERRAL Completed By Role: Paediatrician/GP How long Other professionals involved with the child (e.g. psychologist, OT, speech therapist) Reason for this referral List
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
Insurance information
Pediatric Sleep Intake Paperwork Today s date: Completed intake paperwork helps our providers get to know patients and their medical history. We rely on its accuracy and completeness to provide the best
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health
J. Van Lier Ribbink, M.D., F.A.C.S. Center for Endocrine and Pancreas Surgery at Honor Health Patient Clinical Information Questionnaire 1.0 Date of Questionnaire Completion; / / 2.0 Patient Data 2.1 Name:
Evergreen Speech & Hearing Clinic, Inc. Transforming Lives Through Improved Communication Since 1979
Evergreen Speech & Hearing Clinic, Inc. Transforming Lives Through Improved Communication Since 1979 www.everhear.com Audiology Hearing Testing VRA VNG/VEMP OAE BAER/ECochG Hearing Aids Cochlear/Bone Implants
+ Monica Michael MA LPC LLC
+ Monica Michael MA LPC LLC 5242 Plainfield Ave NE, Suite C Grand Rapids, MI 49525-1084 Phone: 616.970.1599 Fax: 616.734-6205 Email: monica.m.michael@gmail.com Website: neurofeedbackcounselor.com Intake
JOHN MICHAEL ROACH, MD
GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA 99301 Phone: (509) 546-8383 Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy:
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
Autism Spectrum Disorder What is it?
Autism Spectrum Disorder What is it? Robin K. Blitz, MD Director, Developmental Pediatrics Resident Autism Diagnostic Clinic Lecture Series #1 Learning Objectives What can we talk about in 20 minutes?
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG DATE SOC. SEC. NUMBER FULL NAME DATE OF BIRTH ADDRESS: STREET TOWN STATE ZIP PHONE: HOME WORK CELL EMPLOYER OCCUPATION ADDRESS
Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio
927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On
Fragile CLINIC. Expert Help for Children with Fragile X Syndrome
x Fragile CLINIC Expert Help for Children with Fragile X Syndrome Fragile X syndrome is the most common inherited cause of intellectual disabilities in children. It is also one of the leading known causes
SLEEP LOG INSTRUCTIONS. Please keep a daily log of your child's sleep for every day (for up to two weeks) before their clinic visit.
SLEEP LOG INSTRUCTIONS Please keep a daily log of your child's sleep for every day (for up to two weeks) before their clinic visit. To show the time your child gets in bed, please mark that time with a
Where is your pain located? Please use the diagram below to indicate where most of your pain is located.
Name: Address: Social Security Number: Email Address: Emergency Contact: Primary Care Physician: Name: Address: Phone Number: Date of Birth: Today's date: Cell Phone Number: Phone #: Referring Physician:
Neurological Comorbidity
Neurological Comorbidity Ann M Neumeyer, MD Child Neurology Medical Director, Lurie Center for Autism Disclosures Neither I nor my spouse/partner has a relevant financial relationship with a commercial
Silver Child Development Center New Patient Questionnaire. Relation (circle) Biological Mother Stepmother Adoptive Mother
Silver Child Development Center New Patient Questionnaire Today s Date Mother s Name First Last Date of Birth Relation (circle) Biological Mother Stepmother Adoptive Mother Foster Mother Other Father s
Vision Care for Connecticut Children
Vision Care for Connecticut Children EXECUTIVE SUMMARY November 2003 Prepared by: Judith Solomon, JD Mary Alice Lee, PhD Children s Health Council With funding from: Children s Fund of Connecticut, Inc.
SLEEP EVALUATION QUESTIONNAIRE
Directions Please answer each of the following questions by writing in or choosing the best answer. This will help us know more about your family and your child. CHILD S INFORMATION Child s name: Child
*Please feel free to ask your child s doctor for help with filling out this form or contact our 22q Center Nurse at
Child s Name Today s Date Parent(s)/Guardian(s) Child s DOB Age Address Phone Parent s email Who is completing this form (name and relation to patient) Insurance Provider Subscriber s Name Subscriber ID
+ Color Change - + Hearing Loss - + Apnea - + Enuresis (urine - + Tremors - + Rash -
Review of Systems: 0-1 year old Constitution neg Eyes neg GI neg Neurological neg + Activity Change - + Eye Discharge - + Reflux - + Facial Asymmetry - + Appetite Change - + Eye Redness - + Vomiting -
Feeding Disorders and Growth in Williams Syndrome
Feeding Disorders and Growth in Williams Syndrome Sharon M. Greis M.A., CCC/SLP BRS-S and Paige Kaplan M.B.B.Ch. Williams Syndrome Clinic The Children s Hospital of Philadelphia Pediatric Feeding & Swallowing
Candida Fink MD. 12 Parcot Avenue New Rochelle NY Phone Fax NEW PATIENT HISTORY
Candida Fink MD 12 Parcot Avenue New Rochelle NY 10801 Phone 877-534-1090 Fax 914-560-2106 NEW PATIENT HISTORY Please enter requested information as completely as possible and fax your New Patient History
BACKGROUND HISTORY QUESTIONNAIRE
BACKGROUND HISTORY QUESTIONNAIRE Name: Sex M F Address: Home Number: Work Number: Cell Number: Email: SSN: Name and Address of Employer: Date of Birth: Age: Ethnicity: Referred By: Referral Question or
SLEEP QUESTIONNAIRE. Name: Home Telephone. Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: Pharmacy & Phone #:
q JHMCE q JHS q SMEH SLEEP QUESTIONNAIRE 1. DEMOGRAPHIC DATA Name: Home Telephone Address: Work Telephone: Marital Status: Date of Birth: Age: Sex: Height: Weight: 2. PHYSICIAN INFORMATION Name of Primary
Cleft-Craniofacial Center
Cleft-Craniofacial Center A Pioneering T eam 2 Welcome to the Cleft-Craniofacial Center at Children s Hospital of Pittsburgh The Cleft-Craniofacial Center at Children s Hospital of Pittsburgh has been
Anna & John J. Sie Center for Down Syndrome Affiliates
Anna & John J. Sie Center for Down Syndrome Affiliates Types of Medical Research Bench or basic research: done in a controlled laboratory setting using nonhuman subjects Clinical research: answer questions
VASCULAR SURGERY PATIENT HEALTH HISTORY
VASCULAR SURGERY PATIENT HEALTH HISTORY Chief Complaint - Please describe the problem that brings you into the office today: Allergies 1. Do you have any allergies? if so, please list To Medications? To
NEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred
Fragile X Syndrome: A Review of Associated Medical Problems
STATE-OF-THE-ART REVIEW ARTICLE Fragile X Syndrome: A Review of Associated Medical Problems AUTHORS: Sharon A. Kidd, PhD, MPH, a Ave Lachiewicz, MD, b,c,d Deborah Barbouth, MD, e Robin K. Blitz, MD, f,g
The Rehabilitation Institute Cancer Rehabilitation
DO NOT DRILL The Rehabilitation Institute Cancer Rehabilitation STAR Patient Intake Form Your Name: Date: Your date of birth: Age: Who referred you (if a healthcare provider, please provide address)? Doctors
Patient Medical History Form Pre-Surgical Bleeding History Questionnaire Name:
Patient Medical History Form Pre-Surgical Bleeding History Questionnaire Name: CIRCLE the appropriate response: Y yes or N no. A. Patient History 1. Has the patient ever had surgery, stitches for trauma
DIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
New Patient Questionnaire
New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist
Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol
PRE-EVALUATION FORM Medical condition SELF Mother Father Sibling (list brother or sister) Anxiety Bipolar disorder Heart Disease Depression Diabetes High Cholesterol High Blood Pressure Obesity Heart Defect
Q&A Summary: Autism Spectrum Disorder (ASD) Part II: Medical Home Care for Children With ASD and Other Developmental Disabilities
Q&A Summary: Autism Spectrum Disorder (ASD) Part II: Medical Home Care for Children With ASD and Other Developmental Disabilities Available On-Demand: optumhealtheducation.com/autism-part-ii-2018 Presenter:
New Patient Information
Geoffrey G Glidden MD PA New Patient Information Name Address City/State/Zip Cell Phone Home Phone DL# SSN# Age of Birth Sex: Male / Female Your employer Occupation Work Phone E-Mail Referring Physician
Clinical Practice Guideline: Tonsillectomy in Children, Baugh et al Otolaryngology Head and Neck Surgery, 2011 J and: 144 (1 supplement) S1 30.
Pediatric ENT Guidelines Jane Cooper, FNP, CORLN References: Clinical Practice Guideline: Tympanostomy tubes in children, Rosenfeld et al., American Academy of Otolaryngology Head and Neck Surgery Foundation
Pediatric Sleep History
Fax 423-431-2983 Pediatric Sleep History Patient/ Child s Name: Date of Birth: Parent Name: Last 4 of Social Security No: Gender: Male Female Height: Weight: Age: Race: Street Address: City: State: Zip:
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE
VCU CENTER FOR SLEEP MEDICINE NEW PATIENT QUESTIONNAIRE Name:_ DOB: MR#: Date: Sex: Age: Height: Referring physician: Primary care physician: What is your primary sleep problem? Please explain any strange
Gender: M F Race: Caucasian African American Hispanic Other
Weight Loss Surgery Patient Information First Name: Middle Initial: Last: Date of Birth: Age: Social Security #: Gender: M F Race: Caucasian African American Hispanic Other Address: City: State: Zip: Home
Georgia Northside Ear, Nose, and Throat, LLC
Andrew Diamond, M.D. Craig Richman, M.D. Joshua Downie, M.D. Keith Jackson, M.D. Lora A. Moszczynski, PA-C Jennifer L. Tirino, M.D. Otology and Thomas Chacko, M.D. Allergy : PATIENT INFORMATION Name of
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Sleep Apnoea. The Story of a Pause
Sleep Apnoea The Story of a Pause There is almost zero awareness in India that many amongst us maybe living with Sleep Apnoea, which left untreated could be life threatening tomorrow. This largely undiagnosed
San Francisco Ear Nose & Throat Medical Group, Inc
SF ENT San Francisco Ear Nose & Throat Medical Group, Inc Adult & Pediatric Otolaryngology Hearing Disorders Endoscopic Sinus Surgery Head & Neck Surgery Thomas L. Engel, M.D. Vanessa R. Erickson, M.D.
Providence Medical Group
Providence Medical Group To our valued patients: In order to provide you with our full attention when you come for an appointment, we would like to ask you to be aware of the following guidelines. Insurance