Patient History Form / Questionnaire

Patient History Form / Questionnaire

The following information is a true and accurate account of_________________________________ medical, physical and mental condition. I am providing______________________________ with a copy for records and/or insurance purposes only. All information is confidential and may not be released to other individuals by ________________________________ without my written consent.

______________________________

Parent / Guardian Signature

The following information is a true and accurate account of this patient’s medical, physical and mental condition.

______________________________

Physician / Therapist / RN Signature

Date____________________

Patient Name_________________________________ Date of Birth_______________

Patient Height__________________ Patient Weight____________________

Address_______________________________________ Phone__________________

City_______________________________ State__________ Zip Code_____________

Patient Diagnosis ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

MEDICAL INFORMATION

Does this patient have seizures? ____________

If yes, what type? __________________________________________________________________

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How often do they occur? _________________________________________________

What seizure medication is he/she taking? ___________________________________

______________________________________________________________________

Do the seizures compromise his/her respiratory status? _________________________

If yes, in what way? _____________________________________________________

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In what way do the seizures cause potential injury? _____________________________

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Does he/she require special positioning not feasible with a standard bed? ____________________

Does he/she require frequent and/or rapid changes in position? ____________________________

Does the need for special positioning relate to respiratory, GI, cardiac, and/or orthopedic problems? _______________________

What respiratory problems exist that require special positioning? ________________________________________________________________________________________________________________________________________________________________

Does he/she require any routine treatments for chronic respiratory problems? __________________

If yes, what type? __________________________________________________________________

Does he/she ever require prompt intervention for a medical crisis? _______ If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Has he/she required hospitalization related to these respiratory problems? ______________

If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What GI or swallowing disorders exist that require special positioning? ________________________________________________________________________________________________________________________________________________________________

What GI medication is he/she presently taking? _________________________________________

Has he/she had any medical complications as a result of this disorder? _____________

If yes, please explain: ________________________________________________________________________________________________________________________________________________________________

Has he/she had surgery for a GI disorder? ____________

If yes, please explain type and result: __________________________________________________

________________________________________________________________________________________________________________________________________________________________

Does he/she require special feedings? _____________

If yes, what type and why? ___________________________________________________________

What cardiac disorders exist that require special positioning? ________________________________________________________________________________________________________________________________________________________________

What cardiac medication is he/she taking? _____________________________________________

Have there been any surgical interventions? ________________________

If yes, what type? __________________________________________________________________

BEHAVIORAL INFORMATION

Is he/she self abusive? ____________

If yes, explain _____________________________________________________________________

________________________________________________________________________________________________________________________________________________________________

What type of injuries has he/she sustained? _____________________________________________

Has he/she ever required medical attention for a self inflicted injury? _____________________

If yes, explain: ____________________________________________________________________

What medications have been tried to reduce this behavior? _________________________________

What behavioral modifications have been tried to reduce this behavior? _______________________

Does he/she tolerate confined areas? ___________________________________

Does he/she prefer confined areas? ____________________________________

If yes, explain: ____________________________________________________________________

Does he/she have any sleep disturbances? _________________________________

What is the average amount of sleep per night?__________________________________

Have any and if so, what medications have been tried to induce sleep? _____________________________________________________________________________________________________________________________________________________________

What behavioral modifications has been tried to improve sleep habits? _______________________

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Does he/she attempt to wander during the night? _______________________________________

What potential problems exist because of wandering? _____________________________________

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Does he/she recognize danger or show fear? ________________________________________

Does he/she continue with inappropriate behaviors despite danger? __________________________

If yes, please describe specific instances: _______________________________________________

Has he/she been found in any dangerous situations or sustained any minor injuries during night time wandering attempts? _________________________________________

If yes, explain: ____________________________________________________________________

Has he/she required medical attention for any injuries sustained during the night time wandering attempts? ________________________________________________________________________

________________________________________________________________________________

Does loss of sleep/rest affect his/her health and/or behavior? _______________________________

If yes, explain: ____________________________________________________________________

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Does he/she exhibit PICA behavior (tried to eat/chew inedible objects)? _______________________

If yes, explain: ____________________________________________________________________

Does he/she have any injuries resulting from this PICA behavior? ___________________________

If yes, explain: ____________________________________________________________________

PHYSICAL INFORMATION

Does he/she have abnormal muscle tone? _____________________________________________

If yes, describe: ___________________________________________________________________

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Does he/she have proper coordination and protective responses? ___________________________

If no, explain: _____________________________________________________________________

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Can he/she sit independently? ______________________________________

Can he/she pull to tall kneel? _______________________________________

Can he/she pull to stand? __________________________________________

Can he/she safely resume to sitting from a standing position? _______________________________

If no, what occurs? _________________________________________________________________

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Can he/she walk? ____________________________________________

If non ambulatory, is he/she mobile by other means (crawl, roll, scoot, etc)? ____________________

If yes, explain: ____________________________________________________________________

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Is he/she ataxic or lose balance easily? _______________________________________

Has he/she sustained any minor injuries during falls from this poor balance or control? ___________

If yes, explain: ____________________________________________________________________

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Has he/she sustained any injuries from poor balance or control that have required medical attention? ________________________

If yes, explain: ____________________________________________________________________

FAMILY SUPPORT

Who are his/her primary caregivers? __________________________________________________

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How many caregivers are in the home during the night time? __________________________

Do the primary caregivers have outside jobs? Who? ______________________________________

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How many other children/dependents are cared for in the home? ____________________________

Does he/she receive any skilled nursing care? __________________________

How many hours per week or month? _____________________________

Does he/she receive any aide or respite care? _______________________________

How many hours per week or month? _____________________________

Does he/she attend day care, school, or any other program? ________________________________

If yes, what type? __________________________________________________________________

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BED OPTIONS

What is his/her current bed? _________________________________________________________

Why is this bed no longer appropriate? _________________________________________________

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Has he/she been endangered or injured because of present bed? ____________________________

If yes, explain: ____________________________________________________________________

Have you considered/tried a standard bed with side rails? __________________________________

Is this type of bed appropriate or inappropriate? ______________________________________

What features of the current bed in use cause concern or problems? ________________________________________________________________________________

Have you considered/tried a hospital crib? ________________________________

Is that type of bed appropriate or inappropriate? ________________________________________

What features of this bed cause concern or problems? _____________________________________

Will bumper pads for standard beds or cribs provide adequate protection? _____________________

If no, explain: _____________________________________________________________________

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Have you considered/tried a mattress on the floor? _______________________________________

Is this option appropriate or inappropriate? _______________________________________

What problems or concerns are the regarding this bed option? ______________________________

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Have you considered/tried chemical or tie down restraints? ______________________________

Are those appropriate or inappropriate? _______________________________________

What problems or concerns are there regarding their use? _________________________________

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Have you considered a SleepSafe Bed for him/her? _____________________________________

Is this an appropriate option to meet the needs of the patient? ________________________

What are the specific features of a Sleep Safe Bed that make it most appropriate for this patient?

Of all available bed options, what is your request/recommendation? __________________________

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Additional Comments: