Pediatric Intake Questionnaire

Pediatric NEW PATIENT QUESTIONNAIRE

We look forward to meeting you at your upcoming appointment! To best serve you and your child at your visit, we would appreciate your responses to the following questions. Also, please bring any MRI scans and EEG test results along with hospital records with you to the visit.

Child's Name

First Last

Nickname

Birth Date

Physician Who Referred You To Us

Physician's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

A. History of Pregnancy, Delivery, and Neonatal course

Age of mother at the time of delivery

Please enter a number greater than or equal to 17.

Number of previous pregnancies

Number of miscarriages(if any)

Number of months pregnant

Complications Of Pregnancy

Was Labor spontaneous or induced?

Duration of labor

Type of delivery and/or complications

Baby's Weight

Lbs

Oz.

Apgar Score

Please indicate if your child experienced any of the following during the Newborn Period.

Sucking or feeding:

Infection, including meningitis:

Jaundice or high bilirubin

Breathing, requiring artificial ventilation:

Convulsions or seizures:

Total number of Days in Nursery:

B. Developmental Milestones

Please write in the age when your child accomplished the following, if known.

MOTOR

Rise on forearms and lift head:

Turned over front to back:

Turned over back to front:

Sat alone:

Crawled:

Stood alone:

Walked unassisted:

Rode a tricycle:

Rode a bicycle:

LANGUAGE AND SOCIAL SKILLS

Smiled in response to seeing you:

Spoke first words:

Spoke two words together:

Is speech adequate for age?

Does your child understand as well as other children his or her age?

Speech Therapy (if any):

FINE MOTOR AND COORDINATION

Grasped for objects:

Feed himself/herself:

Tie his/ her own shoelaces:

Button own clothes:

SCHOOL/EDUCATION

Your child’s current school level:

Any specific issues or therapies required in school?

C. FAMILY MEDICAL HISTORY

Are both parents alive?

Are there any diseases that run in the family?

Any family members with seizures?

Any members with learning problems?

D. MEDICAL HISTORY

Please indicate if your child ever had any of the following illnesses or reactions.

Encephalitis or meningitis:

Operations:

Head injury with loss of consciousness:

Febrile Seizures:

An allergic reaction to medication:

If yes, which medication(s):

Other allergies:

Other medical issues:

E. GENERAL SYMPTOMS

Please indicate if your child had any of the following symptoms.

Problems with vision:

Loss of hearing:

Large changes in weight:

Persistent nausea/vomiting:

Headaches:

Fainting spells or blackouts:

Change in memory:

Hyperactivity:

Weakness in one part of the body:

Tremor or involuntary movement:

Numbness in one part of the body:

Clumsiness or unsteadiness:

Persistent or high fever:

Skin Rash:

Pain in joints, neck or back:

Asthma:

Change in bowel and/or bladder habits:

Bleeding or clotting:

F. SEIZURE HISTORY

SEIZURE HISTORY

If your child has seizures, please describe a typical event and how often they occur currently.

G. SEIZURE MEDICATION HISTORY

Please indicate which medications, if any, your child has taken and how they responded.

Acetazolamide (Diamox)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

ACTH

Age/Duration

Better/Worse/No change

Side Affects Yes/No

B6 Vitamin (Pyridoxine)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Brivaracetam (Briviact)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Cannabidiol (Epidiolex)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Carbamazepine (Tegretol)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Cenobamate (Xcopri)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Clobazam (Onfi, Sympazam, Frisium)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Clonazepam (Klonopin)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Clorazepate (Tranxene)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Diazepam (Valium)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Eslicarbazepine (Aptiom)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Ethosuximide (Zarontin)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Everolimus (Afinitor)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Fenfluramine (Fintepla)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Felbamate (Felbatol)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Gabapentin (Neurontin)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Lacosamide (Vimpat)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Lamotrigine (Lamictal)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Levetiracetam (Keppra)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Lorazepam (Ativan)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Oxcarbazepine (Trileptal)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Perampanel (Fycompa)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Phenobarbital (Luminal)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Phenytoin (Dilantin)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Prednisone

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Pregabalin (Lyrica)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Primidone (Mysoline)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Rufinamide (Banzel)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Stiripentol (Diacomit)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Tiagabine (Gabitril)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Topiramate (Topamax)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Trimethadione (Tridione)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Valproic Acid (Depakene/Depakote)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Zonisamide (Zonegran)

Age/Duration

Better/Worse/No change

Side Affects Yes/No

Thank you!

Thank you for your time in providing this information. We look forward to seeing you!