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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