MGUH Organic Autism Request an Appointment form-3345501 - Formstack

Request an Appointment

MedStar Georgetown Autism and Communications Disorders Clinic

Child's Name*

First Name

Last Name

Date of Birth*

Knowing your date of birth helps us offer you a more efficient experience.

Gender*

Does your child have any allergies?*

Yes No

Please list all allergies*

Parent/Guardian*

First Name

Last Name

Insurance*

Best Phone Number To Contact You*

Email*

How did you hear about this clinic?*

Pediatrician*

First Name

Last Name

Pediatrician's Phone*

What was the reason you were referred for the evaluation?*

What are your concerns about your child?*

Please check any that apply: (Mother)*

congenital malformation developmental delay intellectual disability Autism Spectrum Disorder Grandfather (maternal side) seizure disorder neurological condition genetic condition medical condition

Please write conditions (Mother)*

Please check any that apply: (Grandmother (maternal side))*

congenital malformation developmental delay intellectual disability Autism Spectrum Disorder Grandfather (maternal side) seizure disorder neurological condition genetic condition medical condition

Please write conditions (Grandmother (maternal side))*

Please check any that apply: (Grandfather (maternal side))*

congenital malformation developmental delay intellectual disability Autism Spectrum Disorder Grandfather (maternal side) seizure disorder neurological condition genetic condition medical condition

Please write conditions (Grandfather (maternal side))*

Please check any that apply: (Father)*

congenital malformation developmental delay intellectual disability Autism Spectrum Disorder Grandfather (maternal side) seizure disorder neurological condition genetic condition medical condition

Please write conditions (Father)*

Please check any that apply: (Grandmother (paternal side))*

congenital malformation developmental delay intellectual disability Autism Spectrum Disorder Grandfather (maternal side) seizure disorder neurological condition genetic condition medical condition

Please write conditions (Grandmother (paternal side))*

Please check any that apply: (Grandfather (paternal side))*

congenital malformation developmental delay intellectual disability Autism Spectrum Disorder Grandfather (maternal side) seizure disorder neurological condition genetic condition medical condition

Please write conditions (Grandfather (paternal side))*

Are there any additional doctors or specialists involved in your child’s care?*

Yes No

Number of Physicians involved*

Specialty of Physician (ENT, GI, Geneticist)*

Name of Physician*

First Name

Last Name

Date Last Seen*

Phone Number*

Specialty of 2nd Physician (ENT, GI, Geneticist)

Name of 2nd Physician

First Name

Last Name

Date Last Seen (2nd Physician)

Phone Number (2nd Physician)

Specialty of 3rd Physician (ENT, GI, Geneticist)

Name of 3rd Physician

First Name

Last Name

Date Last Seen (3rd Physician)

Phone Number (3rd Physician)

Specialty of 4th Physician (ENT, GI, Geneticist)

Name of 4th Physician

First Name

Last Name

Date Last Seen (4th Physician)

Phone Number (4th Physician)

Please list all medical diagnoses your child has:

Number of Diagnoses*

Diagnosis*

Age at time of Diagnosis*

Name of Physician who Diagnosed*

First Name

Last Name

2nd Diagnosis

Age at time of 2nd Diagnosis

Name of Physician who Diagnosed (2nd Diagnosis)

First Name

Last Name

3rd Diagnosis

Age at time of 3rd Diagnosis

Name of Physician who Diagnosed (3rd Diagnosis)

First Name

Last Name

4th Diagnosis

Age at time of 4th Diagnosis

Name of Physician who Diagnosed (4th Diagnosis)

First Name

Last Name

Please list all medications your child takes:

Number of Medications *

Medication*

Dosage*

Route (oral, nasal)*

Frequency*

Physician who prescribed*

Start Date*

Stop Date

2nd Medication

Dosage (2nd Medication)

Route (oral, nasal) (2nd Medication)

Frequency (2nd Medication)

Physician who prescribed (2nd Medication)

Start Date (2nd Medication)

Stop Date (2nd Medication)

3rd Medication

Dosage (3rd Medication)

Route (oral, nasal) (3rd Medication)

Frequency (3rd Medication)

Physician who prescribed (3rd Medication)

Start Date (3rd Medication)

Stop Date (3rd Medication)

4th Medication

Dosage (4th Medication)

Route (oral, nasal) (4th Medication)

Frequency (4th Medication)

Physician who prescribed (4th Medication)

Start Date (4th Medication)

Stop Date (4th Medication)

Please list any special tests, procedures, and/or hospitalizations since birth (MRI, EEG, surgery):

Number of special tests, procedures, and/or hospitalizations since birth*

Date*

Procedure*

Reason for Testing*

Results of Procedure*

Date (2nd Procedure)

Procedure (2nd Procedure)

Reason for Testing (2nd Procedure)

Result of Procedure (2nd Procedure)

Date (3rd Procedure)

Procedure (3rd Procedure)

Reason for Testing (3rd Procedure)

Result of Procedure (3rd Procedure)

Date (4th Procedure)

Procedure (4th Procedure)

Reason for Testing (4th Procedure)

Result of Procedure (4th Procedure)

Development

Please indicate if your child’s developmental skills are achieved on time or delayed for each category:

Gross motor skills (sitting up, crawling, walking): *

age-appropriate delayed

Age*

Self-Care Skills (drinking from cup, finger feeding, dressing self): *

age-appropriate delayed

Age*

Speech-language skills (understanding words, saying first word): *

age-appropriate delayed

Age*

Feeding

Please list any problems with eating: *

Does your child self-feed? *

Finger Utensils

Other:

Does your child have regular bowel movements? *

Yes No

*

Constipation Diarrhea

Other:

How many per day? *

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