Child English Intake - My Doctor Online The Permanente Medical ...
Child English Intake - My Doctor Online The Permanente Medical ...
Child English Intake - My Doctor Online The Permanente Medical ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
~ KAISERPERMANENTE"<br />
------------<br />
Prenatal and Birth<br />
Was your child adopted? 0 Yes 0 No If Yes, at what age?<br />
IMPRINT AREA<br />
How wasthe biologicalmother's healthduringpregnancy? 0 Good 0 Fair 0 Poor 0 N/A<br />
How old was the biological mother when the child was born? o Unknown<br />
Did the motheruse any of the followingsubstancesor medicationwhilepregnant?<br />
o Alcohol 0 SleepingPills 0 Heroin 0 DiabetesMedication<br />
o Tranquilizers 0 Marijuana 0 Methamphetamine 0 Cigarettes<br />
o Antibiotics 0 Cocaine 0 Anti-SeizureMedication<br />
Other:<br />
Did toxemiaor eclampsiaoccurat birth? 0 No 0 Yes 0 Unknown<br />
<strong>The</strong> childwasborn: 0 Before8 months 0 Atterm (8-10months) 0 10months 0 Unknown<br />
Werethereany complicationsduringlabor?0 No 0 Yes (pleaseexplain) 0 Unknown<br />
~M_'_' " ' '__' '_M_________________________________________.___._______...___._____..___.____..___._..__.._......__.....<br />
Did the child experience any of the following during delivery? (Check all that apply)<br />
o Normal 0 Caesarian 0 Breech 0 Forceps 0 Induced 0 FetalDistress 0 Unknown<br />
Werethereany healthcomplicationsfollowingbirth? 0 No 0 Yes(pleaseexplain)? 0 Unknown<br />
M._._.___._________________________ --.--.------.-.-.---------------.---.---.--<br />
-------.--.--.-.---.----.----.-.--------------.--.---.-------.---------.----.-.-.-.-.-------....---<br />
Infancv and Development<br />
Were there early infancy feeding problems? o No DYes o Unknown<br />
.Was the child colicky (difficult to soothe, cried a lot)? o No DYes o Unknown<br />
Were there infancy sleep pattern difficulties? o No DYes o Unknown<br />
Were there problems with the infant's alertness?<br />
. - <br />
o No DYes o Unknown<br />
w_______.._<br />
How easy was it to get the child calm and on a schedule? (check one)<br />
. 0 YetyJ~.~~Y 0 Ea~y" 0 Av~~<br />
How sociable was the child with other people? (check one)<br />
_!;JV efY-_~oc!a~!.t? P Ay-erag~_s()ciability ------.---.--..---.-------<br />
o Less sociable<br />
What was the child's activity level as an infantltoddler:(check one)<br />
Very active Active<br />
--------------.-----.-.--..------.---.-<br />
ODD<br />
Less active<br />
Where there any delays in developmental milestones, such as sitting up, crawling, walking, talking or toilet<br />
training? 0 No 0 Yes (please explain) 0 Unknown<br />
-_.~- ..---<br />
-.--------------------.-.---. w ~__.___<br />
-..-.----..----------<br />
<strong>Child</strong> <strong>Intake</strong> 11.2009.sgc 2
Change language