ࡱ> BU?@A #bjbj++ 4II3+%NN8D8,X$dd"aaa/#1#1#1#1#1#1#$P%(U#uaauuU#$AAAud/#Au/#AA !* ǷR #($0X$ ,(+(!!(#!aL6A,faaaU#U#jaaaX$uuuu(aaaaaaaaaN n: RUSH CHILD DEVELOPMENTAL PROGRAM CHILD INTAKE QUESTIONNAIRE Date: Parents Name: Childs Name:  (Mr) Birth Date M F (Mrs/Ms)Address County Phone:Work: Cell:Language (s) spoken at home: Referral Information Childs Physician Name:Address:Phone:Who referred you for evaluation?Phone: Insurance Company Name:Group/Identification Number:Source of Guardianship (Parents/DCFS/Other) If DCFS, Caseworkers Name:  Phone:Your ConcernsPlease list the problems with which you want help with your child:What have you been told in regards to your childs problems?How do you think we might be able to help you and your child?Pregnancy History Number DatesLive Births ___ _________________________________________________Stillborn ___ _________________________________________________Miscarriages ___ _________________________________________________Abortions ___ _________________________________________________ Did you have any problems becoming pregnant with this child? Yes____ No____If so, what specialists were seen, what tests were done, and what medications were prescribed?Did Mother receive prenatal care? __Y __N When did it begin? _____ weeks Mothers age at time of Birth: _____ yearsDuring this pregnancy, did the mother have any of the following?Excessive nausea/vomiting m  Rh Incompatibility m Edema/Swelling m  Convulsions/Seizures m Toxemia/High Blood Pressure m  Rashes m Vaginal bleeding or spotting m  Emotional Stress m Chicken Pox m  Bladder or Kidney Infection m German Measles m  Sexually transmitted disease(s)m Weight Loss (how much?): m  Fever-How High? m Smoking-How many cigarettes per day? _ Alcohol-how many drinks per day/week? _Medications:Other: Labor and deliveryWas child born at Full term? ___Y ___NIf no, how early? Number of weeks ________Delivery: Vaginal m C- Section m Presentation: Head first m Breech m Birth Weight: _____Length: ____APGAR Scores:1 minute: ____5 minutes: _____Any complications:Newborn PeriodWhere was your child born?How long was the hospital stay? MotherBabyWas the child in Neonatal Intensive Care?If yes, how long?Please list any complications that your child presented with before being discharged from the nursery or neonatal intensive care unit:What diagnosis, if any, was made at birth?Childs Medical HistoryPlease indicate if your child has had any of the following:  Yes/ No Age Yes/No AgeFrequent colds m m ___Heart problems m m ___Allergies/Hay Fever m m ___Tics/twitches m m ___Asthma m m ___High fever m m ___Pneumonia m m ___Scarlet Fever m m ___Whooping Cough m m ___Mumps m m ___Bronchitis m m ___Measles  m m ___Croup m m ___Meningitis m m ___Colic m m ___Chicken Pox  m m ___Hearing problems m m ___Recurrent Stomachaches  m m ___Burns m m ___Constipation/Bowel Problems  m m ___Skin disease m m ___Urinary problems  m m ___Paralysis m m ___Vision Problems  m m ___Headaches/dizziness m m ___Ear Infections/Ear Fluid  m m ___Loss of consciousness m m ___Foot Problems  m m ___Seizures m m ___Head Injury  m m ___Anemia m m ___Fractures  m m ___Birthmarks m m ___Accidents or Falls  m m ___Other:Immunizations:Up to Date? Yes____ No____Unusual Reactions:HOSPITALIZATIONS & EMERGENCY ROOM VISITS:Name of HospitalDate:Reason:MEDICATIONS YOUR CHILD IS CURRENTLY RECEIVING:Other specialists consulted:DateType of EvaluationName of SpecialistResultsDiet/nutrition: Circle the items that concerns you regarding your childs diet:AppetiteEatingFood allergies or intolerancesSelf-feeding skillsWeightOther/Explain:Elimination: Circle the items that concern you:ConstipationDiarrheaToilet TrainingBedwettingOther/ExplainSleep:What time does you child go to sleep at night?What time does your child wake up in the morning?Does your child sleep through the night?Does your child go back to sleep on his/her own?How long is your child awake at night?Does your child snore?How many naps does your child take during the day? How Long?Is bedtime behavior a problem?If yes, please explain:Other concerns about sleep:Childs Developmental HistoryAt what age did your child demonstrate the following:Able to hold head up __________Babbling ___________Roll over __________Say first word ___________Sit up without support __________Use two-word combinations ___________Crawl forward __________Respond to his/her name ___________Pull up to stand __________Use pointing to make a request ___________Walk without holding on __________Potty training ___________Has your child lost any skills? Behavior:How frequently does your child have temper tantrums?How long do the tantrums last?Is your childs behavior a concern at home and/or school? Please explain.What are your childs favorite activities?Does your child exhibit any aggressive behaviors? 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Where and Type:Has your child ever been recommended for therapy (i.e., occupational, physical, speech, etc.)?Is there any other information concerning your childs educational history you would like for us to know about?Family Medical HistoryPlease indicate if any member of the family has had problems such as cognitive delays, seizures, hearing loss, reading difficulties, school problems, mental or emotional disorders, physical disabilities, muscle problems, cleft lip or palate, clubfoot, other.Family MemberYesNo Please describe:FatherMotherBrothers/SistersPaternal GrandfatherPaternal GrandmotherPaternal Great-grandparentsMaternal GrandfatherMaternal GrandmotherMaternal Great-GrandparentsPaternal Aunts/UnclesMaternal Aunts/UnclesPaternal CousinsMaternal CousinsSocial HistoryFather:Name:Age:Date of Birth:Address:Martial Status:Health:Occupation:Employer:How Long:Years of School Completed:Ethnic Background:White, not HispanicBlack, not HispanicHispanicOther. Specify:Mother:Name:Age:Date of Birth:Address:Martial Status:Health:Occupation:Employer:How Long:Years of School Completed:Ethnic Background:White, not HispanicBlack, not HispanicHispanicOther. Specify:Step-Parent/Foster Parent/Guardian (circle one, if appropriate)Address:Martial Status:Health:Occupation:Employer:How Long:Years of School Completed:Ethnic Background:White, not HispanicBlack, not HispanicHispanicOther. Specify:Brothers and Sisters:NamesSexAgeProblems, if anyNumber of people in the home over the age 18: Number of people in the home under the age of 18:Who cares for your child during the day? (Name and Relationship)RELEASE OF INFORMATION: In order to have a better understanding of your child particular needs, it is important to gather background information from some of the places and people that have cared for your child. Please sign the attached consent for release of information form and list the names and addresses of any of the places where your child has received care relating to this referral, including hospitals, agencies, speech/occupational therapy, counseling, etc. PLEASE FAX OR MAIL THIS FORM TO: ATTN Rosa Figueroa 1725 W. 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