Pediatric Intake Form

Patient Name: ______ ______, Date of Birth: ______
Patients Preferred Name: ______
Age: ______
Primary Care Physician: ______

______ ______ is a ______ year old patient presenting to the WVU Medicine Family-Based Pediatric Medical Weight Management Clinic. 

Patient Grade: ______
Who Lives in the home: ______
Who buys food for the home: ______
Who makes food in the home: ______

The patient states the following on what they want to get out of this visit. "______"

Patient's weight history is as follows: ***

Patient reports the following answers to food security questions:
Within the past 12 months were you worried your food would run out before you got money to buy more? ______
Within the past 12 months, the food you bought didn't last and you didn't have money to buy more? ______

Diet/Food History:
Food allergies: ______ 
The patient reports the following food behaviors: ______

Eating Out (times per week)
Fast Food Restaurants: ______ 
Sit-Down Restaurants: ______

Fruits and Vegetables (per day):
Vegetables: ______ 
Fruits: ______

Drink history (servings per day):
Juice: ______ 
Milk: ______
Chocolate Milk: ______
Flavored Milk: ______
Diet Soda: ______
Regular Soda: ______
Coffee: ______
Energy Drinks: ______
Diet Tea: ______
Sweet Tea: ______
Sports Drinks: ______
Water: ______

Screen Use History (hours per day):
TV: ______
Computer for nonschool-related activities: ______
Phone/Tablet: ______

Activity: 
Does the child participate in sports: ______
How long is your child active during the day: ______

Sleep History:
Weekday Bedtime: ______
Weekday Wake: ______
Weekend Bedtime: ______
Weekend Wake: ______

Has screens within 30 minutes of bedtime: ______
Has a TV, computer, or phone in the bedroom: ______
Snores: ______
Had evaluation for enlarged tonsils: ______
Feels sleepy during the day: ______

School:
The patient reports missing ______ days of school this year.

Other information the parent/guardian would like us to know in this visit: ______

Standardized Scales: 
Child Feeding Questionnaire
  Perceived Responsibility: ______ out of 5
  Perceived Parent Weight: ______ out of 5
  Perceived Child Weight (whole score): ______
  Concern About Child Weight: ______ out of 5
  Restriction: ______ out of 5
  Pressure to eat: ______ out of 5
  Monitoring: ______ out of 5

Child Eating Behavior Questionnaire

  Food Responsiveness:  ______
  Emotional Over Eating: ______
  Enjoyment of Food: ______
  Desire to Drink: ______
  Satiety Responsiveness: ______
  Slowness in Eating: ______
  Emotional Under-Eating: ______
  Food Fussiness: ______

Add .pedswtnew

WVU Medicine Pediatric Psychology - Initial Assessment

PATIENT NAME: ______ ______
PATIENT'S PREFERRED NAME: ______
DATE OF BIRTH: ______
VISIT DATE: @ED@
AGE AT VISIT: ______
TIME IN/OUT: ***
PROCEDURE: ***
Primary Care Physician: ______

Reason for referral: ______ ______ is a ______ year old patient presenting to the Medical Weight Management Pediatric Clinic. They were referred to assess needs for individual and family support for initiating and maintaining healthy lifestyle changes. The caregiver states the following: "______" as their goals for today's visit. 

The patient and family were seen in conjunction with the multidiscplinary Family Weight Management Team and additional information can be obtained from team clinic notes for today's visit. 




Presenting Concern: 
______ ______ is here today with ***.  ______ provided information via initial intake paperwork and completed assessment measures.  The family provided additional information during today's appointment about their concerns.  
In regards to health status and eating behaviors, ______ reported today that their weight is ______ and height is ______ feet ______ inches.  This calculates to a self-reported BMI of [bmi_ped].  Via the intake form, ______ reports that ______ buys food for their household. They report that ______ makes meals in the household. 
During today's appointment, the patient and family reported ***. 




Current Diet/Eating Habits: 

The parent reports the following food behaviors: ______.  They report that their family eats meals together *** and eats meals at fast food restaurants ______ times per week and sit-down restaurants ______ times per week. 
In regards to specific diet habits, the parent reports that the child eats ______ servings of vegetables and ______ servings of fruits each day. 
Drink habits are reported to be as follows: 
Juice: ______ 
Milk: ______
Chocolate Milk: ______
Flavored Milk: ______
Diet Soda: ______
Regular Soda: ______
Coffee: ______
Energy Drinks: ______
Diet Tea: ______
Sweet Tea: ______
In regards to food security, the ______ reported the following answers:  
Within the past 12 months were you worried your food would run out before you got money to buy more? ______
Within the past 12 months, the food you bought didn't last and you didn't have money to buy more? ______




Social History: 
______ lives with ______.  ***
______ is in ______ at ***.  The report ______ missed school days this year.  They report that school ***




Developmental History: 
Pregnancy:  WNL
Birth weight:  *** lbs, *** oz.
Developmental milestones:
                      Verbal:  WNL
                      Gross motor: WNL
                      Fine motor:  WNL
                      Social:  WNL
                      Adaptive:  WNL
                      Early Intervention (e.g. Birth to Three):  No
Self care;  ______ is currently able to complete age-appropriate self-care tasks.  


Relevant Medical History: 
Current health and medical status: ***
Allergies, including medication allergies: ______
Illness, injuries, chronic conditions, disabilities, physical or sensory limitations: ***
Brain Injury: ***
Current medications: @MEDS@
Medical hospitalization: ***
Surgery: ***
Sleep:  Weekday bedtime: ______
             Weekday waketime: ______
             Weekend bedtime: ______
             Weekend waketime: ______
             Has screens within 30 minutes of bedtime: ______
             Has a TV, computer, or phone in the bedroom: ______
             Snores: ______
             Had evaluation for enlarged tonsils: ______
             Feels sleepy during the day: ______
Screen Use (hours per day):
TV: ______
Computer for nonschool-related activities: ______
Phone/Tablet: ______
Trauma History: ***
Neglect:  Denied 
Physical abuse: Denied
Sexual abuse: Denied
Witness to violence: Denied
Major loss or disruption: Denied
Multiple/out-of-home placement(s): Denied


STANDARDIZED TESTING:
**TESTING CODE=96130 (UNIT/HOUR)

The parent completed several self-report measures on behalf of their child as part of today's evaluation.

Child Eating Behavior Questionnaire: The Child Eating Behavior Questionnaire, CEBQ, is a 35-item parent report measure assessing children's eating behaviors.  The scale provides information on 8 different scales relating to relevant behaviors that contribute to eating. Results of today's report are:

Food Responsiveness: ______

Satiety Responsiveness: ______

Food fussiness: ______

Slowness in eating: ______

Emotional overeating: ______

Emotional undereating: ______

Enjoyment of food: ______

Desire to drink: ______

These results indicate: ***

Child Feeding Questionnaire: The Child Feeding Questionnaire (CFQ) is is a self-report measure to assess parental beliefs, attitudes, and practices regarding child feeding.  The CFQ provides scales related to different factors influencing parent behaviors related to child eating. 

Perceived Responsibility: ______

Concern about child weight: ______

Restriction: ______

Pressure to eat: ______

Monitoring: ______

Perceived child weight: ______

Perceived parent weight: ______

These results indicate:   ***


PROMIS Anxiety: The PROMIS anxiety scale is an 8-question paret-report measure addressing symptoms of anxiety for children 8+.  Raw scores are converted to scaled scores as follows:

Raw Score       T-score range      T-score interpretation
8-17                          < 50                   Typical/Normative
18-20                       50-55                 Mild
21-24                       55-65                 Moderate
25+                           65+                     Severe

PROMIS anxiety score: ______

These results indicate: A low/moderate/high concern for anxiety.  ***

PROMIS Depression: The PROMIS depression scale is a 6-question parent-reported measure addressing symptoms of depression for children 8+.  Raw scores are converted to scaled scores as follows:

Raw Score       T-score range      T-score interpretation
6-9                          < 50                   Typical/Normative
10-12                       50-55                 Mild
13-18                       55-65                 Moderate
19+                           65+                     Severe

PROMIS depression score: ______

These results indicate: A low/moderate/high concern for depression.  ***

ASSESSMENT AND MENTAL STATUS:
 
______ was appropriately groomed and dressed for season and occasion. Speech and thought process was goal directed/coherent, and thought content was appropriate.  Mood was euthymic. Affect was consistent with mood.  Eye contact was observed WNL.  Attention, concentration, impulse control were observed WNL.  ______ displayed WNL judgment and insight.  No concerns about suicidal and homicidal ideation, plan and intent, hallucinations and delusions were reported today. ______ was oriented to person, place and time and no evidence of a formal thought disorder was observed.

Diagnosis: ***

Recommendations/Plan: ***