Patient And Family Provided Information (PFPI)

HTTP://WWW.COLUMBIASMA.ORG PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER DARRYL C. DE VIVO, MD HARKNESS PAVILLION, SUITE 525 180 FT. WASHINGTON AVE., NEW YORK, NY 10032 PETRA KAUFMANN, MD PHONE: 212-342-0263, FAX: 212-342-6865 JUAN PASCUAL, MD, PHD Patient and Family Provided Information (PFPI) Page 1 of 7 PATIENT NAME

PATIENT INFORMATION PATIENT DATE OF BIRTH PATIENT’S SCHOOL GRADE MRN

CONTACT INFORMATION MOTHER ’S NAME(S) FATHER’S NAME(S)

STREET ADDRESS AND APT # STREET ADDRESS AND APT #

CITY, STATE, AND ZIP CODE CITY, STATE, AND ZIP CODE

EMAIL ADDRESS EMAIL ADDRESS

HOME TELEPHONE HOME TELEPHONE

WORK TELEPHONE WORK TELEPHONE

CELLULAR PHONE CELLULAR PHONE

FAX FAX

INSURANCE INFORMATION INSURANCE COMPANY POLICY NUMBER (OF CHILD)

PLAN TELEPHONE NUMBER OF INSURER

REFERRING PHYSICIAN INFORMATION MD NAME TELEPHONE

STREET ADDRESS (INCLUDE OFFICE/SUITE #) FAX

CITY, STATE AND ZIP CODE EMAIL

I hereby authorize direct payment of medical benefits to ______for services rendered by him/her in person.

I understand that I am financially responsible for any balance not covered by insurance. I hereby authorize ______to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. PATIENT’S (OR LEGAL GUARDIAN’S) SIGNATURE DATE: HTTP://WWW.COLUMBIASMA.ORG PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER DARRYL C. DE VIVO, MD HARKNESS PAVILLION, SUITE 525 180 FT. WASHINGTON AVE., NEW YORK, NY 10032 PETRA KAUFMANN, MD PHONE: 212-342-0263, FAX: 212-342-6865 JUAN PASCUAL, MD, PHD Patient and Family Provided Information (PFPI) Page 2 of 7 PATIENT NAME

COMPLETE ALL SECTIONS OF THIS FORM. WHAT IS THE REASON FOR TODAY’S VISIT FOR EXAMPLE, (INCREASING UNSTEADINESS WALKING FOR LAST SIX MONTHS):

REVIEW OF SYSTEMS. Place a check mark in the ‘Normal’ checkbox if the child has no symptoms related to that system; underline any symptoms that are present and add comments or additional symptoms in ‘Findings’. SYSTEM SYMPTOMS FINDINGS CONSTITUTIONA L FEVER, WEIGHT LOSS, FATIGUE, RECURRENT INFECTION, UNUSUAL ODORS OF BODY FLUIDS NORMAL EYES DOUBLE VISION, LOSS OF VISUAL ACUITY, BLURRING, CATARACTS, STRABISMUS, NEED FOR NORMAL GLASSES

EARS, NOSE AND HEARING LOSS, RINGING IN THE EARS, VERTIGO, THROAT AURAL (EAR) DISCHARGE, INFECTIONS, CONGESTION, HOARSE VOICE, DIFFICULTY NORMAL SWALLOWING, DENTAL SYMPTOMS

RESPIRATORY SHORTNESS OF BREATH, WHEEZE, COUGH, COUGHING UP BLOOD, BLUE DISCOLORATION, NORMAL ALTERED PATTERN OR BREATHING.

CARDIOVASCULA CHEST PAIN, ABNORMAL RATE OR RHYTHM, R ABNORMAL BLOOD PRESSURE, SHORTNESS OF NORMAL BREATH, SWELLING OF ANKLES.

GASTROINTESTI DIARRHEA, CONSTIPATION, NAUSEA, VOMITING, NAL RECTAL BLEEDING, BLACK, TARRY BOWEL MOTIONS, WEIGHT LOSS OR GAIN, JAUNDICE, NORMAL SPECIFIC FOOD INTOLERANCE OR AVERSION GENITOURINARY BLOOD IN THE URINE, PAIN ON URINATION, NORMAL LOIN PAIN, IMPOTENCE INTEGUMENTARY DARK OR LIGHT PATCHES ON THE SKIN, NORMAL RASH, CHANGES IN HAIR OR NAILS MUSCULOSKELE TAL JOINT PAIN OR SWELLING, SMALL LUMPS UNDER THE SKIN, SKELETAL DEFORMITIES NORMAL PSYCHIATRIC MOOD CHANGES, DELUSIONS, HALLUCINATIONS NORMAL

ENDOCRINE SYMPTOMS OF THYROID, ADRENAL, ISLET CELL, NORMAL PARATHYROID DISEASE

HEMATOLOGICAL {PALE APPEARANCE, LOSS OF ENERGY, AND LYMPHATIC ENLARGEMENT OF LYMPH NODES, ABNORMAL NORMAL BLEEDING OR CLOTTING

ALLERGIC RUNNING NOSE, EYES, OR NORMAL SKIN REDNESS OR SWELLING ABNORMALITIES OF HIGHER FUNCTION NEUROLOGICAL (INCLUDING SPEECH AND LANGUAGE), STRENGTH, COORDINATION, SENSATION, NORMAL DEVELOPMENT; SEIZURES OR OTHER SPELLS; HEADACHES HTTP://WWW.COLUMBIASMA.ORG PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER DARRYL C. DE VIVO, MD HARKNESS PAVILLION, SUITE 525 180 FT. WASHINGTON AVE., NEW YORK, NY 10032 PETRA KAUFMANN, MD PHONE: 212-342-0263, FAX: 212-342-6865 JUAN PASCUAL, MD, PHD Patient and Family Provided Information (PFPI) Page 3 of 7 PATIENT NAME

NEUROMUSCULA EXERCISE INTOLERANCE, DARK URINE (COCA R COLA COLORED), MUSCLE TWITCHING, NORMAL CRAMPING, MUSCLE PAIN, MUSCLE STIFFNESS

PREGNANCY AND DELIVERY LENGTH OF PREGNANCY (WEEKS)

DELIVERY METHOD (VAGINAL, VACUUM EXTRACTION, FORCEPS, CAESARIAN SECTION)

PLACE OF DELIVERY

BIRTH WEIGHT

FOLIC ACID BEFORE CONCEPTION Y N

USE OF ANTENATAL VITAMINS AND IRON Y N

X-RAYS, RADIATION EXPOSURE OR THERAPY (IF “YES,” PLEASE EXPLAIN) Y N

INFECTIONS (IF “YES,” PLEASE EXPLAIN) Y N

PRESCRIBED MEDICATIONS (IF “YES,” PLEASE EXPLAIN) Y N

ALCOHOL/TOBACCO/DRUGS (IF “YES,” PLEASE EXPLAIN) Y N

DIABETES Y N

HIGH BLOOD PRESSURE Y N

OTHER PROBLEMS (IF “YES,” PLEASE EXPLAIN) Y N

LENGTH OF LABOR (HOURS)

APGAR SCORES

JAUNDICE Y N

RESUSCITATION Y N

ABNORMALITIES NOTED AT BIRTH (IF “YES,” PLEASE EXPLAIN) Y N HTTP://WWW.COLUMBIASMA.ORG PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER DARRYL C. DE VIVO, MD HARKNESS PAVILLION, SUITE 525 180 FT. WASHINGTON AVE., NEW YORK, NY 10032 PETRA KAUFMANN, MD PHONE: 212-342-0263, FAX: 212-342-6865 JUAN PASCUAL, MD, PHD Patient and Family Provided Information (PFPI) Page 4 of 7 PATIENT NAME INTENSIVE CARE (IF “YES,” PLEASE EXPLAIN) Y N

DEVELOPMENTAL MILESTONES. Please check ‘normal’ if he or she attained the milestones in the range indicated; otherwise record the time the milestone was attained with any comments. MILESTONE [USUAL RANGE FOR TERM INFANTS] NORMAL TIME ACHIEVED OTHERWISE

REGARDS (LOOKS AT) TOY [NEWBORN]

TURNS TO SOUND [0-2 MONTHS]

HOLDS TOY [1-2 MONTHS]

TRIES TO REPEAT SOUNDS, COOS, BLOWS BUBBLES [2-4 MONTHS]

HOLDS WITH BOTH HANDS [4-5 MONTHS]

TRANSFERS HAND TO HAND [5 –6 MONTHS]

KNOWS OWN NAME, BABBLES – ‘BA, MA, GA’ [5-7 MONTHS]

REACHES WITH ONE HAND [4-7 MONTHS]

PINCER GRASP [7-12 MONTHS]

SITS ALONE AT LEAST 10-30 SECONDS [5-8 MONTHS]

STANDS HOLDING FURNITURE [6-12 MONTHS]

POINTS TO NOSE ON REQUEST, SAYS ‘MAMA, DADA’, REPEATS SOUNDS AND WORDS [8-12 MONTHS]

STANDS ALONE [9-16 MONTHS]

WALKS ALONE [9-17 MONTHS]

WALKS UPSTAIRS WITH HELP [12-23 MONTHS]

IDENTIFIES FAMILIAR OBJECTS, 10-50 WORDS [13-20 MONTHS]

JUMPS OFF FLOOR WITH BOTH FEET [17-30+ MONTHS]

WALKS UP STAIRS ALONE, BOTH FEET ON EACH STEP [19-30+ MONTHS]

UNDERSTANDS SIMPLE QUESTIONS, 50-75 WORDS, TWO WORD SENTENCES, STUTTERS [18-24 MONTHS]

PEDALS TRICYCLE, RUNS SMOOTHLY [4 YEARS] HTTP://WWW.COLUMBIASMA.ORG PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER DARRYL C. DE VIVO, MD HARKNESS PAVILLION, SUITE 525 180 FT. WASHINGTON AVE., NEW YORK, NY 10032 PETRA KAUFMANN, MD PHONE: 212-342-0263, FAX: 212-342-6865 JUAN PASCUAL, MD, PHD Patient and Family Provided Information (PFPI) Page 5 of 7 PATIENT NAME

WALKS DOWNSTAIRS, CATCHES BOUNCED BALL, JUMPS ON ONE FOOT [5-6 YEARS]

PEDALS BICYCLE [7 YEARS]

SCHOOL PERFORMANCE RECORD CURRENT AND PAST GRADES, INDICATING AREAS OF STRENGTH AND WEAKNESS

BEHAVIOR (DESCRIBE ANY CONCERNS):

MAJOR ILLNESSES/INJURIES/SURGERIES DATE/AGE ILLNESS/INJURY/SURGERY TREATING PHYSICIAN/HOSPITAL

DRUG THERAPY (PAST AND PRESENT). List all prescribed medications, including dose and times; also list all vitamins, herbal and dietary supplements and other substances including caffeine and alcohol. NAME DOSE STARTED ENDED (NOTE IF CURRENT)

IMMUNIZATIONS. If all completed without problems, write ‘Up-to-date’; otherwise, please specify immunizations given and any problems encountered, or those missing and why.

ALLERGIES OR ADVERSE EFFECTS FROM MEDICINES. List name of medicine and describe effect; write ‘None’ if there is no history of such events. NAME OF DRUG OR ALLERGEN EFFECT (E.G. RASH, ASTHMA) DATE OF EVENT(S) HTTP://WWW.COLUMBIASMA.ORG PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER DARRYL C. DE VIVO, MD HARKNESS PAVILLION, SUITE 525 180 FT. WASHINGTON AVE., NEW YORK, NY 10032 PETRA KAUFMANN, MD PHONE: 212-342-0263, FAX: 212-342-6865 JUAN PASCUAL, MD, PHD Patient and Family Provided Information (PFPI) Page 6 of 7 PATIENT NAME

FAMILY HISTORY. Include details of illnesses, including neurologic, learning or behavioral problems. Please include deceased members of the family, with age and cause of death where known. RELATIONSHIP NAME(S) AND AGE(S) ILLNESSES

BROTHERS AND SISTERS

MOTHER

FATHER

MOTHER’S FATHER

MOTHER’S MOTHER

FATHER’S FATHER

FATHER’S MOTHER

OTHERS

SOCIAL HISTORY. Who does the child live with? Please describe your family’s circumstances (all individuals living in the household and their relationships to the patient and each other.

SIGNATURE PRINT NAME AND RELATIONSHIP DATE HTTP://WWW.COLUMBIASMA.ORG PEDIATRIC MDA/SMA NEUROMUSCULAR CENTER DARRYL C. DE VIVO, MD HARKNESS PAVILLION, SUITE 525 180 FT. WASHINGTON AVE., NEW YORK, NY 10032 PETRA KAUFMANN, MD PHONE: 212-342-0263, FAX: 212-342-6865 JUAN PASCUAL, MD, PHD Patient and Family Provided Information (PFPI) Page 7 of 7 PATIENT NAME PHYSICIAN’S SIGNATURE PHYSICIAN NAME DATE