TEXAS CHILD NEUROLOGY, LLP
1708 Coit Rd. Suite 150
Plano TX 75075
Ofc. 972-769-9000 Fax 972-769-0035
Robert Chudnow, MD Anthony Riela, MD
Van Miller, PhD, MD Gerald So, MD
Patient's Name__________________________________________________________________________
Date of Birth ______________________Grade________________ School _________________________
Pediatrician or Family doctor __________________ Office phone ______________ Fax ______________
Child’s Problem: Please write a brief chronological description of the condition: Use back if needed
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
CURRENT MEDICATIONS:
Medication Dosage How Often ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
LIST DRUG ALLERGIES ______________________________________________________
Has your child had any of these tests?
TEST DATE WHERE RESULTS
MRI ______ _______________ normal abnormal
CT _______ _______________ normal abnormal
EEG _______ _______________ normal abnormal
Other tests:
Has your child had all the immunizations necessary for his or her age? YES NO
Any hospitalizations for illness or evaluation of a medical (nonsurgical) problem?
Any operations?
Has your child ever complained of or been seen by a physician for:
Dizziness Frequent Vomiting Skin Problems
Headaches Feeding Problems Blurred or abnormal vision
Slow Development Difficulty tolerating cold Fainting spells
Hearing Problems Learning Difficulties Difficulty tolerating heat
Seizures without fever Growth Failure Chronic fatigue
Seizures with fever Hyperactivity Carsickness
Migraine Headaches Genetic Diseases Mental illness
Sleeping problems Birth defect Weakness of muscles
Abnormal weight loss/gain Tingling in feet or hands
Pregnancy and newborn history:
How long did you carry your child? ___________ Child's birth weight ______________
Medications during pregnancy_______________________________________________
Problems in pregnancy: Illnesses___________ Infections__________ Bleeding________
Labor:
Spontaneous Induced Length of labor _____________hoursDelivery: Vaginal C-section Were forceps used? YES NO
Any difficulties? ________________________________________________________________
Any breathing problems at birth? YES NO
Did your child come home from the hospital with you? YES NO
If not, when?___________
Growth and developmental milestones:
At what age did your child:
Roll over _______________ Sit ____________________ Say first words __________
Walk __________________ Speak in sentences _______ Toilet train _____________
Past Health
Any serious or chronic illness or diagnosed disorders in this child?
Did you have any special concerns about your child's development or behavior when he/she was a toddler? When pre-school age?
How has your child performed in school? Please consider each year of school and address academic performance and behavior.
Has the school system provided any special accommodations for your child?
What are your child's interests or hobbies?
MOOD INVENTORY (if appropriate)
Does your child make self-deprecatory statements such as: "I'm dumb" or "I'm stupid" or "nobody likes me" or "they are all picking on me" ? _____________________Can your child have fun? ___________ Does he/she have a problem with anger? __________ Has there been any sexual acting out? _________ Is your child often silly, giddy, rude or crude? __________
Does your child have a difficult time falling asleep at night? ___________________________
Does he/she awaken in the night and have difficulty going back to sleep?_________________
Will he/she often visit you during the night or ask to sleep in your room? _________________
Does your child sleepwalk, sleeptalk, grind teeth or have excessive nightmares? ____________
Will he/she tend to fall asleep at school, in the car or during boring activities? ______________
Has there been recent lying? ____ Stealing? _____ Cruelty to animals?____ Fire setting? _____
Is your child distractible?____ Impulsive? _____ Accident-prone? _____ Intrusive (nosey) _____
Is your child a daredevil? _______ Is he/she destructive? ______ Affectionate? _____________
How is your child's modesty? ____________________ Pain tolerance?____________________
Is your child too sensitive to criticism? _________ phobias or compulsions? _______________
Family history
Please list your child’s brothers and sisters and their ages.
____________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Please recall family members to the best of your ability back to the patient’s grandparents.
Condition Mother Father Mother’s Parents Father’s Parents Child’s Siblings
Asthma
Bleeding Disorder
Cancer
Diabetes
Heart Disease
High Blood Pressure
Kidney Disorder
Thyroid Disease
Brain Tumor
Cerebral Palsy
Dementia
Depression
Learning Disability
Manic-depression
Mental Illness
Mental Retardation
Migraine Headache
Multiple Sclerosis
Muscle Disease
Neurofibromatosis
Parkinson’s Disease
Peripheral Neuropathy
Seizures
Stroke
Any other medical conditions that run in the family not mentioned above?
Are there family members who have substance abuse (alcohol or drugs)? ___________________
Are any family members in prison? _____Have any family members attempted suicide? _______
IMPORTANT: How do you hope that your physician at Texas Child Neurology will be able to help your child? Anything else you would like to tell the doctor not already covered in this questionnaire?