DBP Fast Track and Young Child Intake

Transcription

1 Phone Numbers: Appointments Office DBP Fast Track and Young Child Intake INTAKE QUESTIONNAIRE Please take the time to complete this packet prior to your child s first appointment. This will allow us to learn more about your child so that we can better help him or her. If a particular question or section does not apply, please skip to the next item. General Information Reserve this space for the medical record sticker Who referred you for this evaluation? Pediatrician Birth to Three Parents Other: The referring doctor and/or your primary care physician will be updated with the results of our evaluation. Nickname (if any): Today s Date: Age: Date of Birth: Gender: Male Female Person Completing Form: Relationship to Child: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Child s Primary Care Doctor: Phone: ( ) Fax: ( ) Other Doctor / Therapist Significantly Involved: Phone: ( ) Fax: ( ) Please tell us about the reasons you have scheduled this evaluation: What do you hope to gain from this evaluation? Page 1 of 12

2 Do you have any concerns about your child s skills for each of the following? Difficulty initiating and sustaining conversation Echolalia (repeats words or sounds other people say or make) Decreased ability to understand language Language Yes No Not sure Inconsistent response to name Limited functional communication (using language to communicate with others and make his/her needs known) Minimal or no spoken language Has the ability to use full sentences, but often uses single words/phrases to communicate Minimal use of gestures to communicate (pointing, waving, shaking head, etc.) Difficulty understanding what your child says Scripting (e.g., from TV shows, movies or videos) or repetitive language Unusual rhythm, intonation, or speaking pattern Social Skills Yes No Not sure Inconsistent or decreased eye contact Decreased interest or initiation with peers Delayed or absent pretend play skills Delayed or absent imitation skills Decreased sharing of experiences with others Less spontaneous give and take interactions than expected Interactions mostly focus on specific repetitive interests demand Interactions mostly to meet a demand or want Difficulty with transitions Excessive need for sameness or routine Self-injurious behavior (e.g. head banging, hitting self) Unpredictable or frequently changing mood Prolonged or frequent tantrums Behaviors Yes No Not sure Do you have concerns about any of the following behaviors? Please describe them below. Behavior Comments Hyperactivity, impulsivity, and/or inattention Irritability or aggression Intense or unusual interests Stubborn or oppositional behavior Repetitive behaviors Page 2 of 12

3 Sensitivity to: Yes No Not sure Food texture Restricted diet Fit of clothing, shoes, tags Dirt, grass, sand or other textures Specific sounds Pressure Bathing Getting haircut Touch M-CHAT Ages and Stages Questionnaire ADOS Other: Screening Pass Fail Not done What are your child s strengths and interests? Page 3 of 12

4 Your Child s Development As best as you can remember, list the age or check off the appropriate time at which your child reached the following developmental milestones. Sat without support Crawled Developmental Skill Walked without assistance Hopped on 1 foot Helped get dressed Smiled at you socially Enjoyed Peek a Boo Was upset when you left him/her? Played with a group of children? Counted to 3 Named colors Named objects Named body parts Able to follow simple directions Laughed Babbled Said: bye bye, mama, dada Spoke with 2 word phrases Spoke in sentences Help feed him/herself Toilet trained Age, if known If age cannot be recalled Early Average Late Not Yet Please explain any past development concerns: Page 4 of 12

5 Evaluations and Services Has your child been evaluated by the Birth to Three program? Yes No At what age did Birth to Three Services start? What is your child s Birth to Three classification? Autism Developmental Delay Speech Delay Other: Did his or her classification ever change? Yes No Explain: What Birth to Three services did or does your child receive? Yes No Number of hours per week Provider Speech Therapy Occupational Therapy Physical Therapy Behavioral Therapy Special Education Teacher Is your child enrolled in a Public School Early Intervention Program? Yes No Does your child have an Individualized Family Service Plan (IFSP), Individualized Education Plan (IEP) or 504 Plan? IFSP IEP 504 Plan None What is your child s educational classification? Autism Developmental Delay Speech Delay Other: What school services does your child receive? Yes No Number of hours per week Provider Speech Therapy Occupational Therapy Physical Therapy Behavioral Therapy Special Education Teacher Extended School Year (ESY) Paraprofessional Social Skills training Other Page 5 of 12

6 School Information Please complete the following information about your child s current school/pre-school/daycare. School Name Type of school Public Private Magnet Other Current Grade/Classroom Name of the teacher(s) Number of teachers/aides in class Number of students in class Type of classroom Mainstream Special education Integrated (both) Does your child have an aide assigned to him or her in class? How satisfied are you with your child s current school placement and services? Yes Very satisfied Somewhat satisfied Not satisfied No Has your child had any previous developmental evaluations? Yes No Age Where was the testing? School testing IQ testing Neuropsychiatric testing Hearing or vision evaluation Genetic testing Please explain any significant results: Page 6 of 12

7 Birth History Birth weight: Hospital city and state: How many weeks was your child born at? Delivery type: Vaginal C-section If C-section, why? Mother s age at delivery: Father s age at delivery: Please check if any of the following happened during your pregnancy: High blood pressure Diabetes Trouble gaining weight Early labor/bed rest Bleeding Infection Medication prescribed Abnormal amniocentesis/fetal screening test Drug Use Fertility treatments Recent miscarriage Thyroid problems Alcohol Use Tobacco Use Other problems/illnesses If you checked any of the above, please explain: Were there any problems during labor or delivery? If yes, please explain: Please check if there were problems with the following right after birth or during the first year of life: Intensive Care/Special Care Jaundice Weight gain nursery stay Feeding Sleeping Stooling Colic/Excessive crying Hearing Vision Infections Hospitalizations Other problems If you checked any of the above, please explain: Page 7 of 12

8 Your Child s Health Please check if your child currently has, or had in the past, any of the following medical problems listed below: Autism Vision problem Hearing problem Seizures or staring spells Intellectual disability Anemia/low blood count Elevated lead level Heart problem Constipation Developmental delay Fainting/Dizziness Abnormal newborn screen test Speech Delay Genetic Syndrome Other problems If you checked any of the above, please explain. Additionally, please provide information about any serious illnesses your child has experienced. If you require additional space for any of these sections, use the back of the page. Are your child s immunizations up to date? Yes No If no, why not? Please list any hospitalizations or surgeries your child has had. Reason for Hospitalization/Surgery Age Comments Please list all the medications that your child is currently taking, including any over-the-counter medications, vitamins, or nutritional supplements. Also, please tell us if your child is on a special kind of diet. Medications/Supplements/Diet Start Date Dose & Frequency Comments Please list any medications that your child has taken in the past for mood, behavior, or other developmental/behavioral issues: Medications Start/End Date Dose & Frequency Comments Page 8 of 12

9 Please list any allergies your child has to medications, foods, or the environment below. Allergy Describe Reaction Please list any medical specialists your child has seen now or in past, and provide approximate date of most recent visit. Specialist Date Reason for Visit Please list any specialized medical testing your child has had (e.g., EEG, EKG, MRI, chromosome test), and the result if known. Test Date Result Diet and Sleep History Yes No Explain 1. Feeding/Eating 2. Sleeping Is your child a picky eater? Is your child sensitive to food textures? Does your child over stuff their mouth? Does your child sleep through the night? What time does your child go to bed? What time does your child wake up? Please provide additional information about any areas above, as well as any other concerns you many have regarding your child s diet and sleep. Did your child seem to develop normally but then lose developmental skills? Yes No If yes, please describe: Page 9 of 12

10 Who lives at home? Your Child s Home and Environment Name Age Relationship to Child Level of Education Are the child s parents Married Partners Separated/Divorced, since Other Please describe current custody arrangements: Parents Employment: Mother Childcare: Parents Other (please describe) Father Please check if your child and/or family have experienced any of the following events in the past year: Death of a family member or close friend Marriage / marital reconciliation Divorce / separation Gain of a new family member by birth, adoption, or remarriage Pregnancy Change in residence Financial problems / loss of job Imprisonment Major illness or injury Increase in number of arguments with partner Substance / alcohol abuse Other family stressors If you checked any of the boxes, how much did this impact your family? Not at all Somewhat A lot Please provide additional information about any items checked above. On the following table, please check any boxes that apply to your child and describe when and for how long. Has your child witnessed or Physical abuse/violence experienced the following? If yes, explain and provide approximate Sexual abuse/violence dates. Psychological/emotional abuse Has Child Protective Services ever been involved with your child? Yes No Case worker: Contact number: Page 10 of 12

11 Your Child s Family Health Please indicate if any of your child s relatives have any of the following disorders. Disorder ADHD, Attention or Hyperactivity Problems Autism Spectrum Disorder, Asperger Syndrome, PDD Developmental Delay Intellectual Disability Mental Retardation Learning Problems Dyslexia Physical Disabilities Anxiety, Obssessive- Compulsive Disorder, PTSD Bipolar disorder Relationship to Child Mother s side Father s Side Describe Depression Schizophrenia or psychosis Alcohol / drug use Headaches / Migraines Neurological disorders Seizures / Epilepsy Tics Heart problems Genetic disorders Sudden / unexplained death Thyroid disease Other Thank you for taking the time to provide this information. If you have any questions or concerns, please contact the office at (203) Page 11 of 12

12 Phone Numbers: Appointments Office Fast Track and Young Child Clinic Document Checklist Please bring following documents with you to your intake session. Check each box once you have included the documents. Note: We cannot return or make copies of your documents. Please ensure you have your own copy. Completed Fast Track ASD Intake Questionnaire Ages and Stages Questionnaire (ASQ) Social responsiveness Scale (SRS-2) Modified Checklist for Autism (MCHAT) ONLY for Children UNDER 3 years old You may also send these documents to the office ahead of time: Fax: Courier: (203) Long Wharf Drive Suite 502 Anna.Schairer@yale.edu New Haven, CT Please include appointment date in If you choose to us please include the signed HIPAA form Please include this completed Document Checklist with your Intake Questionnaire. Page 12 of 12