Multi-sheet w pg # no bar

PATIENT SURVEY
CUESTIONARIO DEL PACIENTE
REASON FOR REFERRAL:
(MOTIVO POR EL CUAL SE REFIRIO)_______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________
PAST MEDICAL HISTORY:
(HISTORIA MEDICA PASADA)
Were there any problems with the pregnancy?
(Hubo algunos problemas con el ambarazo?)
Bleeding (Hemorragia)
Diabetes (Diabetes)
Infections (Infeccion)
Trauma (Trauma)
Toxemia (Alta pression de la sangre)
Others (Otros)
Were there any of the following used during pregnancy?
(Fueron usuadas de las siguiented cosas durante el embarazo?)
Medications (Medicamentos)
Alcohol (Alcohol)
Recreational Drugs (Drogas recrectionales)
Tobacco (Tobaco)
Were there any problems with child’s birth?
(Fueron usadas algunas de las siguienetes cosas durante el embarazo?)
Abnormal labor (Parto Anormal)
Abnormal presentation (Presentation fetal anormal)
Breech (Presento de nalgas primero)
Feet first (Presento de pies primero)
Abnormal placenta (Placenta anormal)
Placenta previa
Abruption (Sesprendimiento de la placenta)
Merconium staining (Hubo material evacuado dle intestine del recien nacido)
Forceps delivery (Usaron forcepts)
C-Section (Cesarea)
Birth weight: (Peso de nacer) _____________________
Apgar scores: (Resultados de Apgar) _______________
Date: (Fetcha) __________________________________
Patient name: (Nombre de paciente) ______________________________________
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Were there any problems in the newborn nursery?
(Hubo Algunos problemas en el aula del recien nacido?)
Apnea (Suspencion de la respiracion)
Transfusions
Hypotonia (Tonicidad disminuida)
Seizures (Ataques)
Poor feeding (Almentacion pobre)
Jaundice (lctericia)
Oxygen used (uso oxigeno)
Ventilator (Uso ventilador)
Bleeding into the brain (Hemorragia cerebral)
Abnormal sonogram / CAT scan (Sonogram/CAT scan anormales)
Length of stay (Duration de su estancia en el hospital) __________________
HOSPITALIZATIONS: (Hospitalizaciones)
List dates and problems (Indique fechas y problemas)
SURGERIES: (Cirugias)
List dates and types of surgeries (Indique fechas y tipo de ooperaciones)
OTHER MEDICAL PROBLEMS currently being treated for:
(Otros problemas medicos a los que se les esta tratando ahora)
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MEDICATIONS: (Medicamentos)
List medications your child is presently taking:
(Indique las medicinas que su nino esta tomando ahora)
_________________________________________________________________________________
_________________________________________________________________________________
ALLERGIES: (Alergias)
Medications: (Medicamentos) ___________________________________
Others: (otro) ________________________________________________
IMMUNIZATIONS: (Vacinas)
Immunizations up to date: ____ Yes ____No
(Estan al corrienta todas sus vacunas: ____ Si ____No)
Date: (Fetcha) __________________________________
Patient name: (Nombre de paciente) ______________________________________
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PAST NEUROLOGICAL MEDICAL HISTORY:
(HISTORIA MEDICA NEUROLOGIA PASADA)
Has your child ever been knocked unconscious? ____________________
(Ha su nino alguana vez perdido el conocimiento?) __________________
Has your child ever had meningitis or encephalitis? __________________
(Alguna vez le ha dado a su nino meningitis o encephalitis?) ___________
Has your child ever had a seizure caused by fever? ___________________
(Alguna vez la ha dado a su nino an ataquw causado por fiebre?) ________
Has your child ever had a seizure without fever? _____________________
(Alguna vez le ha dado su nino un attaque sin tener fiebre? ____________
Describe seizure: (Describa el ataque)
_____________________________________________________________________________________
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When was the first seizure? (Cuando le dio el primer ataqua?)
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When was the last seizure? (Cuando le dio el utimo attaque?)
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How often do they happen? (Que tan seguido le dan los ataques?)
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DEVELOPMENTAL HISTORY: What age did your child:
(HISTORIA DE SU DESARROLLO: Ha que edad hizo sun no lo siguiente:)
Rollover (Voltearse): _________________________________________
Sit (Sentarse): _______________________________________________
Crawl (Getear): ______________________________________________
Pull to stand (Jalarse para parase): _______________________________
Cruise (Caminar): ____________________________________________
Learn colors (Aprender colores): ________________________________
Walk independently (Caminar independientemente): ________________
Say first word (Decir su primer palabra): __________________________
Talk in sentence (Hablar en frases): ______________________________
Ride a tricycle (Pasearse en triciclo): _____________________________
Toilet train (Usar el escusado): __________________________________
SCHOOL HISTORY:
(HISTORIA ESCOLAR)
What school district is your child in? (A que distrito escolar pretence su nino?)
______________________________________________________________________
Grade (Grado): ___________________________________________________
What kind of grades does your child make? (Que clase de grados saca su nino?)
______________________________________________________________________
Is your child in a resource class or special education?
(Esta su nino en clases de recurso o educacion especial?)
______________________________________________________________________
Any school discipline problems? (Tiene algun problema deciplina el la escuela?)
Date: (Fetcha) __________________________________
Patient name: (Nombre de paciente) ______________________________________
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FAMILY HISTORY:
(HISTORIA FAMILIAR)
Father’s age (Edad del padre): ____________________________________________
Mother’s age (Edad del madre): ___________________________________________
Brother’s age (Edad de sus hermanos): _____________________________________
Sister’s age (Edad de sus hermanas): _______________________________________
Does anyone in your family have:
(Alguun miembro de su familia padece de lo siguiente:
Seizures (Ataques)
Seizures with fever (Ataques con fiebre)
Migraines (Migranias)
Slow development or mental retardation (Desarrollo tarde o retardo mental)
List any family relative having brain, muscle or nerve disease and what their diagnosis is
and their relationship to the patient: (Inidque cualquier pariente que padezca de enfermedad del
cerebro musculos o de las nervios y cual es su diagnosis y el parentezco co el paciente)
_____________________________________________________________________________________
_____________________________________________________________________________
Is there any family history of:
(Hay en la familia historia de lo siguiente)
Depression (Depression)
Mood swings (Cambio de humor)
Manic depression (Depresion “manic”)
Schizophrenia (Esquizofrenia)
Panic attacks (Ataques de panico)
Drug addiction (Drogadiction)
Violent behavior (Conducta violenta)
SOCIAL HISTORY:
(HISTORIA SOCIAL)
What town or city do you live in?
(En que pueblo o caudad vive usted?)
________________________________________________________________________________
Father’s occupation:
(Ocupacion del Padre)
________________________________________________________________________________
Mother’s occupation:
(Ocupacion del madre)
________________________________________________________________________________
Date: (Fetcha) __________________________________
Patient name: (Nombre de paciente) ______________________________________
Completed by: ________________________________ Relationship to patient: ________________
Date (Fetcha): _________________________ Reviewed by: _______________________________
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