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Forms and Information for Cynthia Fuller M.D. |
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| Dear Parent or Guardian, Welcome to Claremore Developmental Pediatrics. The purpose of this practice is to evaluate children for developmental and behavioral concerns. My hope is to be able to provide these services in an atmosphere that is comfortable to both the children and their concerned parents. I am a General Pediatrician with a special interest in developmental issues. I have spent the last few years with a group in Tulsa that specializes in development, and I hope that I can share a bit of what I have learned from them with my friends in Rogers County and the surrounding area that I call home. I realize that the forms I ask you to complete are a bit tedious. I appreciate your patience with these. This method of collecting information allows me to collect a lot of information without spending a lot of face to face time with you, and therefore a lot of your money. That saves the time we do spend together for very pertinent things such as my observation of your child. I am looking forward to working with you and your child. I honestly try to treat each child as if they were my own. I am very conservative about medication, but I do prescribe it in just the right situation. I do not believe medication will fix every problem. I work closely with the schools to see to it that the child can have the best opportunity to succeed where they are. Thank your for completing the paperwork to the best of your ability. I know that it is time consuming, but the work will pay dividends in the long run for your child's care. Together as we communicate and work together we can help your child with his developmental concerns. Cynthia Fuller M.D.
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PATIENT HISTORY |
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pg. 1 |
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| Patient:______________________________________ Date of birth:_______________________ Age:____________ | ||||||||
| Home address:_______________________________________________________Home phone:_________________ | ||||||||
| City:_________________________________ State:________ Zip:______________Cell phone:__________________ | ||||||||
| PARENTS: | ||||||||
| Child is living with: _____Natural Parents _____Adoptive Parents _____Single Parent | ||||||||
| _____Parent and Step _____ _____Other | ||||||||
| Status of Parents: _____Married _____Separated _____Divorced _____Widowed _____Single | ||||||||
| Legal guardian:_____________________________________ | ||||||||
| Age of child at time of adoption?_________________ Age of child at time of divorce?_________________ | ||||||||
| BIRTH MOTHER: | ||||||||
| Age______ Occupation___________________________ Highest grade completed in school______________________ | ||||||||
| Ever repeat any grades or fail any subjects in school? ________________________________________________________ | ||||||||
| Ever considered to have any behavior problems? ___________________________________________________________ | ||||||||
| Ever been told that mother might have Attention Deficit Disorder or have learning problems?___________________________ | ||||||||
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| Mother's family: Is there any medical or mental illness in the mother's family that might help me understand you child's developmental or behavioral issues better?_____________________________________________________________________________ | ||||||||
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| BIRTH FATHER: | ||||||||
| Age______ Occupation____________________________ Highest grade completed in school_______________________ | ||||||||
| Ever repeat any grades or fail any subjects in school?__________________________________________________________ | ||||||||
| Ever considered to have any behavior problems? _____________________________________________________________ | ||||||||
| Ever been told that father might have Attention Deficit Disorder or have learning problems?_____________________________ | ||||||||
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| Father's family: Is there any medical or mental illness in the father's family that might help me understand you child's developmental or behavioral issues better?_____________________________________________________________________________ | ||||||||
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| Referred by:_______________________________________ | ||||||||
| Patient's doctor:____________________________________ | ||||||||
| What are you concerns about your child?_________________________________________________________________ | ||||||||
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| Has a teacher, therapist, psychologist, or other health care worker ever told you that they were concerned that your child had one of the following conditions: ____cerebral palsy, ____autism, _____epilepsy, ____Attention Deficit Hyperactivity Disorder, ____Attention Deficit Disorder, ____Asperger syndrome, ____Speech delay, ____dysgraphia, ____poor social skills. | ||||||||
| Has your child ever taken medication for ADHD or for autism or a developmental issue? Is it being used now? Please list the medication, when and how long it was used, and your child's response to the medication. Good luck with that memory. | ||||||||
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EDUCATIONAL HISTORY |
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| Preschool or daycare: If you child did attend preschool or daycare how did it go and what feedback did you receive from the caregivers? How many days a week did he attend and what was his age at the start? | ||||||||
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| Current School and Grade: ____________________________________________________________________________ | ||||||||
| Previous Schools Attended: ____________________________________________________________________________ | ||||||||
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| Briefly describe teacher feedback and your concerns during each year of school that your child has completed so far. | ||||||||
| Pre-Kindergarten:____________________________________________________________________________________ | ||||||||
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| Kindergarten:______________________________________________________________________________________ | ||||||||
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| 1st grade: _________________________________________________________________________________________ | ||||||||
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| 2nd grade: _________________________________________________________________________________________ | ||||||||
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| 3rd grade: _________________________________________________________________________________________ | ||||||||
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| 4 th grade: _________________________________________________________________________________________ | ||||||||
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| 5 th grade: _________________________________________________________________________________________ | ||||||||
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| 6 th grade: _________________________________________________________________________________________ | ||||||||
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| 7 th grade: _________________________________________________________________________________________ | ||||||||
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| 8 th grade: _________________________________________________________________________________________ | ||||||||
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| 9 th grade: _________________________________________________________________________________________ | ||||||||
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| 10th grade: _________________________________________________________________________________________ | ||||||||
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| 11th grade: _________________________________________________________________________________________ | ||||||||
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| 12th grade: _________________________________________________________________________________________ | ||||||||
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| Special Education Placement ( now or previously ) | ||||||||
| _______________ Learning Disability placement for the following subjects: | ||||||||
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| _______________ ED Emotionally Disturbed ________________BD Behaviorally Disturbed | ||||||||
| _______Mutihandicapped _______Mentally Retarded/Intellectually Limited (EMH, TMH) | ||||||||
| _______Visually impaired _______Orthopedically impaired _______Hearing impaired | ||||||||
| Has your child ever had any IQ testing or testing for learning disabilities at school or privately? ________ | ||||||||
| Has you child failed any subjects or repeated any grades?_______________________________________________________ | ||||||||
| Did your child attend Developmental Kindergarten or Transitional 1st grade?_________________________________________ | ||||||||
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MEDICAL HISTORY |
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| Birth history: Was your child full term?_______________________ Were there any complications of your pregnancy or the child's delivery?___________________________________________________________________________________________ | ||||||||
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| Has your child been hospitalized since birth?_________________________________________________________________ | ||||||||
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| Does your child currently take any medications for chronic medical conditions? ______________________________________ | ||||||||
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| Is your child or family currently receiving any professional mental health treatment, such as individual or family counseling? ______ | ||||||||
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p. 4 |
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DEVELOPMENTAL AND BEHAVIORAL HISTORY |
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| Please describe your child as an infant in regard to his temperament, sleeping and eating patterns, etc... | ||||||||
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| Infant and Early childhood: Please rank the following as they applied to your child during this phase of development from one extreme to the other, or in between. | ||||||||
| Quiet and content | 1 | 2 | 3 | 4 | 5 | Colicky and irritable | ||
| Very easy to feed | 1 | 2 | 3 | 4 | 5 | Daily feeding problems | ||
| Sleeps well | 1 | 2 | 3 | 4 | 5 | Sleeping problems | ||
| Usually relaxed | 1 | 2 | 3 | 4 | 5 | Often restless | ||
| Under active | 1 | 2 | 3 | 4 | 5 | Over-active | ||
| Cuddly, easy to hold | 1 | 2 | 3 | 4 | 5 | Did not enjoy cuddling | ||
| Easily calmed down | 1 | 2 | 3 | 4 | 5 | Bad tantrums | ||
| Cautious and careful | 1 | 2 | 3 | 4 | 5 | Accident prone | ||
| Coordinated | 1 | 2 | 3 | 4 | 5 | Uncoordinated | ||
| Enjoys eye contact | 1 | 2 | 3 | 4 | 5 | Avoids eye contact | ||
| Enjoys social contact | 1 | 2 | 3 | 4 | 5 | Avoids social contact | ||
| Did any event (health condition, separation, etc...) disturb maternal bonding. Please describe.____________________________ | ||||||||
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| Were your child's developmental milestones reached at about the typical time? _______________________________________ | ||||||||
| Gross motor: example sitting alone, walking, running, riding a bike. ________________________________________________ | ||||||||
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| Fine motor: example feeding self with a spoon, throwing a ball, drawing, tying shoes.___________________________________ | ||||||||
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| Speech: example: says single words, puts words together, says sentences, or asks for things._____________________________ | ||||||||
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| Please list any behaviors that your child exhibits that are concerning to you or other people who care for your child. | ||||||||
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| Please describe any unusual or traumatic events on your child's life that you feel may have had an impact on his or her development or current functioning. This may have been a move, divorce, or health issues.____________________________________________ | ||||||||
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| ______________________________________________________ Signature of Individual completing form. | ||||||||