Pediatric Aerodigestive Disorders Clinic New Patient Questionnaire Completed By: Relationship to Patient: Date



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Pediatric Aerodigestive Disorders Clinic
New Patient Questionnaire


Completed By: ___________________________ Relationship to Patient: ________________________ Date: ___________________
Demographic Information
Patient Name: ______________________________________________ Date of Birth: ______________________________________________________

Address: ____________________________________________________ Phone Number(s): ________________________________________________

Email: _______________________________________________________ Primary / Secondary Languages: ________________________________

Primary Care Provider (PCP): ____________________________ PCP Phone & Fax Numbers: ______________________________________



Family Concerns
What are your concerns that you would like to address in your child’s evaluation? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Social History


  1. Relationship to child

    1. Biological Child _____ Adoption _____ Foster care_____ Surrogacy_____

    2. Age at adoption/foster care placement: ______________

    3. Additional Information: _____________________________________________________________________________________________________

  2. Siblings

    1. Yes _____ No _____

    2. Notes: _________________________________________________________________________________________________________________________



Family Medical History


Relationship to Patient

Medical Condition

Notes

































































Medication & Allergies
Current Medications:


Medication

Dosage

Frequency
























































Allergies to Medications: _____________________________________________________________________________________
Allergies to Food: _______________________________________________________________________________________________

Hospitalizations, Surgeries, & Procedures
Hospitalizations:



Dates

Reason for admission

Hospital Name


































Surgeries & Procedures: (G-tube placement, EGD, laryngostomy/bronchosopy, speech swallow study, etc.)


Date

Procedure Performed

Location of Procedure / Physician















































Patient Medical History
Birth History
Length of Pregnancy: ______________ Type of Delivery: ___________________ Breech position: ____________ Birth Weight: _______________________ Birth Height: ________________________ Apgar Scores: _______________
Medications taken during pregnancy: _______________________________
Prenatal exposure: Alcohol _____ Tobacco _____ Drugs _____ Other _____
Complications (explain):_____________________________________________________________________________________________

_________________________________________________________________________________________________________________________



_________________________________________________________________________________________________________________________


Past or Current Medical Conditions:


Yes No

Does your child experience the following?


If yes, please describe

 

Recurrent ear infections





 

Recurrent colds or sinus infections





 

Recurrent ulcers in mouth





 

Frequent choking or gagging





 

Chronic or recurrent cough





 

Pneumonia





 

Wheezing





 

Environmental allergies





 

Heart murmur





 

Congenital heart disease





 

Appetite change (increase or decrease)





 

Nausea and/or vomiting





 

Frequent spitting up / regurgitation





 

Constipation





 

Diarrhea





 

Abdominal pain





 

Weight loss





 

Food allergies





 

Urinary tract infections





 

Increase or decrease in urination





 

Spasticity or hypotonia





 

Delay in motor skills





 

Delay in speech





 

Sensory issues





 

Fractures or broken bones





 

Skin rash





 

Seizures








Other:







Neonatal Questions:


  1. Neonatal Intensive Care Unit (NICU) Admission:

    1. Yes _____ No ________

    2. Hospital: _____________________________ Length of Admission: _______________________________



  1. Diagnoses:

 Retinopathy of prematurity

Seizures

 Intraventricular Hemorrhage (IVH) Grade ___

 Gastroesophageal Reflux (GERD)

 Periventricular Leukomalacia (PLV)

 Difficulty feeding

 Other: _____________________________________________


  1. Interventions:

 Ventilator / Breathing tube

 Oxygen tube

 Physical Therapy

 Occupational Therapy

Speech Therapy

 Vision Screening

Results:  Pass  Fail

 Hearing Screening

Results:  Pass  Fail
Pulmonology Questions:


  1. Bronchopulmonary dysplasia / chronic lung disease:

    1. Yes _____ No _____



  1. Asthma or Reactive airway disease:

    1. Yes _____ No _____

    2. Inhaler _____



  1. Recurrent pneumonia:

    1. Yes _____ No _____

    2. How often? _________________________ Date of last pneumonia: ___________



  1. Pulmonary Hypertension:

    1. Yes _____ No _____



  1. Cystic Fibrosis:

    1. Yes _____ No _____



  1. Apnea:

    1. Yes _____ No _____



  1. Pulmonary Procedures:

    1. Bronchoscopy _____

    2. Other: ________________________________


ENT Questions:


  1. Hearing Difficulties:

    1. Yes _____ No _____ Right Ear _____ Left Ear _____ Bilateral _____



  1. Newborn Hearing Screen:

    1. Pass _____ Fail _____



  1. Language and Speech:

    1. Understanding words? Yes _____ No _____

    2. Speaking or pronouncing words? Yes _____ No _____

    3. Enrolled in speech therapy? Yes _____ No _____



  1. Indicate symptoms / conditions your child is experiencing:

 Weak voice  Hoarse voice  Gurgly voice

 Sneezing  Clear runny nose  Sinus infection requiring antibiotics

 Noisy breathing  Floppy airway  Laryngomalacia

 Tracheomalacia  Bronchomalacia  Laryngeal cleft

 Restless sleeper  Snoring  Gasps or stops breathing during sleep

 Vocal cord paralysis  Narrowed airway  Tracheoesophageal Fistula (TEF)



Gastroenterology Questions



  1. Stooling Pattern:

    1. Normal _____ Diarrhea _____ Constipation _____ Blood in stool _____ Mucus in stool _____

    2. Number of stools per day _____



  1. Acid Reflux:

    1. Yes _____ No _____ Medication _____ Name of Medication ___________________




  1. Eosinophilic Esophagitis:

    1. Yes _____ No _____ Medication _____ Name of Medication ___________________




  1. Feeding Tube:

    1. Yes _______ No ______

    2. G-tube _____ GJ-tube _____ NG-tube_____ NJ-tube_____

    3. Nissen Fundoplication _______

    4. Size of tube: _______


Nutrition and Speech Therapy Questions:
Feeding Methods:


  1. How does your child currently receive nutrition? Check all that apply:

 G-tube  NG-tube  NJ-tube

 GJ-tube  Sippy cup  Bottle (nipple types: _________________________)

 Open cup  Spoon/fork  Straw

 Hands  Other: __________________________



  1. If your child receives tube feedings, please complete the following:

 Continuous Feeds:

      • Rate: ______ ml/hr

      • Duration: _____ hours

      • Start time: ___________

      • End time: ____________

 Bolus Feeds:

      • Total volume: ______ ml or _____ oz

      • Times Given: ____________________

      • Feeding duration: ___________ minutes


Food Intake:


  1. Please complete the three day diet record attached to the end of this questionnaire if applicable



  1. Indicate the food your child currently takes:

 Breast milk  Formula  Pediasure

 Soft Chewables  Hard Chewables  Chewy foods

 Stage 1 baby food  Stage 2 baby food  Stage 3 baby food

 Pureed Table Foods  Other: __________________________



  1. How long does a meal (or for infants, a bottle) usually take? ______________________________________



Food Behaviors:


  1. Does your child display any of the following behaviors related to feeding?

 Frequent coughing/choking related to feeding

 Gagging/vomiting related to feeding

 Refusal behaviors related to feeding (ie: head turning)

 Difficulty accepting foods of certain textures

 Difficulty chewing

 Holding food in mouth

 Other: ____________________________________________

Development:


  1. Please write the age when your child first performed the following skills (circle months or years)

Sat alone: __ __ (Months/Years) Toilet-trained: ________ _ (Months/Years)

Crawled: ___ _ (Months/Years) Learned to Write: ___ ____ (Months/Years)

Walked: ___ _ (Months/Years) Said a single word: __ _______(Months/Years)

Babbled: ___ _ (Months/Years) Dressed Self: _ _________(Months/Years)

Used a cup: __ _______________(Months/Years) Fed self: _________ ________(Months/Years)


  1. Does your child use any of the following at home or at school?

 Walker  Wheelchair  Special cups/spoons  Pacifier  Sippy cup

 Assistive technology  Infant swing  Exersaucer  Infant “walker” or jumper

 Other:__________________________


  1. Please list any speech or language difficulties: _____________________________________________________________________________________

___________________________________________________________________________________________________________________________________________



  1. Have your child’s language skills regressed? (Lost words, no longer follows directions, etc.) __________________________________

___________________________________________________________________________________________________________________________________________

  1. Does your child repeat or echo certain words or phrases? _________________________________________________________________________


School or Early Intervention: (Complete sections applicable to your child)
Name:_______________________ ____ City/County_ _______________

Grade:_____________________________ Approximate # of Students in Class: _____

Teacher(s):______________________ ________________

Support Services: _____________________________________________________________________________________________


 Individual Family Service Plan (IFSP)  Occupational therapy

 Individual Education Plan (IEP)  Assistive technology

 Adapted PE  Speech therapy

 Physical therapy  Classroom aide

 Other: ___________________________________________________
 Involved in organized activities or sports? __________________________

 Any concerns or difficulties?_______________________________________




General Behavior: (Answer questions applicable to your child)


  1. What are your child’s favorite activities? ________________________________

  2. What motivates your child? __________________________________________

  3. How does child play with brothers and sisters?  Poor  Fair  Well  N/A

  4. How does child play with children his/her own age?  Poor  Fair  Well

  5. What is the length of time your child can attend to an activity? _______________

  6. Does your child have any behavior issues? _____________________________

  7. Does your child have any attention difficulties? ___________________________

  8. Does your child have any repetitive behaviors? (Hand flapping, rocking, lining up toys) ______________________________________

  9. Is your child bothered by certain sensations / feelings?

    1.  Noises Textures, clothing, or touch  Movements  Lights

    2. Please Specify: _________________________________________________________

Three Day Food Log – Aerodigestive Disorders Clinic
Please complete this log only if your child eats solid foods

Child’s Name:_____________________________ Dates of Food Log:_____________________


Time of Day

(i.e., 8:30am)

Food Items Served to the Child (i.e., Enfamil formula, breast milk, stage 1 applesauce, steamed peas)


Amount Child Ate

(i.e., 1 ounce, ½ cup, 2 spoonfuls)

Amount of time the meal lasted

(i.e., 15 min, 45 min)

Behavior/Comments (child’s willingness, interest, behaviors, complaints; coughing/choking, vomiting, food pocketing etc.)




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Amount Child Ate

(i.e., 1 ounce, ½ cup, 2 spoonfuls)

Amount of time the meal lasted

(i.e., 15 min, 45 min)

Behavior/Comments (child’s willingness, interest, behaviors, complaints; coughing/choking, vomiting, food pocketing etc.)




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Time of Day

(i.e., 8:30am)

Food Items Served to the Child (i.e., Enfamil formula, breast milk, stage 1 applesauce, steamed peas)


Amount Child Ate

(i.e., 1 ounce, ½ cup, 2 spoonfuls)

Amount of time the meal lasted

(i.e., 15 min, 45 min)

Behavior/Comments (child’s willingness, interest, behaviors, complaints; coughing/choking, vomiting, food pocketing etc.)




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