Child’s name or label
Since the last visit, how are your child’s symptoms? Better? Worse? The same? Please describe:
Any new health problems, consultations, ER visits, hospital admissions, procedures or surgeries since your last visit?
None
Evaluations or tests done since the last visit: MRI EEG Blood work Child Study Team evaluation Neuropsychological testing ImPACT test Audiology Nutritionist consultation Questionnaires Physician Consultations:______ Other: ______ None
If your child takes medications, please list the medications and doses here: 1.______4.______2.______5.______3.______6.______
PEDS NEURO REVIEW OF SYSTEMS: Please list symptoms your child has since the last visit. Describe “yes” responses.
NEUROLOGICAL KNOWN EYE CONDITIONS YES NO ______
HYPERACTIVITY YES NO ______EAR, NOSE AND THROAT
SEIZURES YES NO ______HEARING LOSS OR DEFICIT YES NO ______
FAINTING YES NO ______SLEEP APNEA YES NO ______
SNORING YES NO ______CARDIOVASCULAR
HEADACHES YES NO ______RAPID OR IRREGULAR HEART BEAT YES NO ______
TICS YES NO ______CHEST PAIN OR EXERCISE INTOLERANCE YES NO ______
INATTENTION YES NO ______ RESPIRATORY
CONCUSSION YES NO ______SHORTNESS OF BREATH YES NO ______
HAS 504 PLAN? YES NO ______HAS IEP ? YES NO ______COUGH OR WHEEZING YES NO ______
CONSTITUTIONAL GASTROINTESINAL
FEVER OR SWEATS YES NO ______NAUSEA OR VOMITING YES NO ______
FATIGUE OR MALAISE YES NO ______ABDOMINAL PAIN YES NO ______
APPETITE TOO HIGH OR TOO LOW YES NO ______CONSTIPATION OR DIARRHEA YES NO ______
BEHAVIORAL HEALTH MUSCULOSKELATAL
WORRIES / ANXIETY YES NO ______MUSCLE WEAKNESS OR PAIN YES NO ______
SCHOOL AVOIDANCE YES NO ______JOINTS PAIN OR DEFORMITY YES NO ______
SADNESS OR DEPRESSION YES NO ______ ENDOCRINE
MOODINESS OR IRRITABILITY YES NO ______EARLY OR LATE PUBERTY YES NO ______
EYES THYROID PROBLEMS YES NO ______
VISION CHANGES YES NO ______SHORT STATURE OR GROWTH HORMONE DEFICIENCY YES NO ______
Parent’s signature ______Physician’s signature ______Date: ______