University of Texas-Houston Health Science Center
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UT Physicians Center for Autism and Related Conditions at CLI
NEW PATIENT FORM
***Please bring this completed form to your child’s first appointment***
|Child’s Name: |Date of Birth: |
|Sex: Male Female |Ethnicity: |Language(s) spoken in home: |
|Who referred you to our center? |
Contact Information for Parent/Guardian completing this form:
|Parent/Guardian Name: |
|Address: |
|City: |State: |Zip: |
|Home Phone: |
|Work Phone: |
|Email address: |
|Relation to patient: |
Pregnancy with this child:
|Age of Mother at delivery: |Age of Father at delivery: |
|Weeks’ gestation at delivery: |Premature |Full Term |Birth Weight: |
|List any medications taken during pregnancy: | |
|List any complications with pregnancy or delivery: | |
|Infant’s age at time of discharge home: | |
Developmental History:
| |Months |Years |
|Sat alone: | | |
|Crawled: | | |
|Walked alone: | | |
|Pedaled tricycle: | | |
|Fed self with fingers: | | |
|Spoke in single words: | | |
|Talked sentences: | | |
|Bowel control: | | |
|Bladder control: | | |
For Office Use: Reviewed by_______________
Do you have any concerns about your child’s speech/language development? YES NO
If “YES” please describe:
| |
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MEDICAL HISTORY of CHILD
| |YES / NO |If “YES” please describe: |
|Any prior hospitalizations: | | |
|Any prior surgeries: | | |
|Any known allergies to medication or food: | | |
|Any vision concerns: | | |
|Any hearing concerns: | | |
|Date of last hearing assessment, with whom, and results: | | |
|Any concerns related to sleep: | | |
|Any concerns related to feeding: | | |
|Any concerns related to seizures or tics (repetitive vocal / | | |
|motor movements): | | |
|Does your child have any prior diagnoses: | | |
|Does your child take any medications daily: | | |
Does your child receive any therapy (Speech/Language, Occupational, etc.): YES NO
If “YES” please describe (type of therapy, frequency, name of provider, etc.):
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Is your child in school or childcare program: YES NO
If “YES” list name of school(s), current grade, any services/supports the child is receiving in school, or any academic/learning concerns you have about your child:
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Briefly describe your concerns about your child and your goals for your visit at our center:
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For Office Use: Reviewed by_______________
UTP Center for Autism and Related Conditions at CLI
6655 Travis Suite 800 Houston, TX 77030
(713) 500-3600 Phone │(713) 383-1482 Fax
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