CLEFT PALATE HISTORY FORM
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1 Harry Jersig Center 411 S.W. 24 th Street San Antonio, TX (210) CLEFT PALATE HISTORY FORM Child s name: Age: DOB: / / Parent/guardian name: Address: City/Zip code: Gender: Height: Weight: Today s Date: Referral by: SS#: - - Insurance Co: Member ID: Contact phone: address: Primary Care (Attending) Physician: Address: Phone Number: History of Problem Please check any of the following that applies to your child: Cleft lip (unilateral) Which side? Cleft lip (bilateral) Cleft palate (unilateral) Which side? Cleft palate (full length) Cleft lip and palate
2 Which of the following cleft/palate symptom(s) applies to your child? Feeding/eating problems Misaligned teeth Poor growth Change in nose shape Failure to gain weight Language Delay Recurrent ear infections Speech sound difficluties Hypernasal voice quality Avoids social situations Flow of liquids through nasal passages during feeding/drinking When was the cleft lip/palate first noticed? Who first noticed the problem? Was surgery performed? Yes No By whom? At approximately what age was your child? Have any further surgeries been performed or recommended for your child? When and by whom? Was there follow-up with specialists after surgery? ENT speech therapist orthodontist plastic surgeon number of visits: number of visits: number of visits: number of visits: other number of visits: specialty:
3 (Circle one) Symptoms are getting : worse better staying the same If worse or the same, please identify the persisting symptoms: Dental cavities Displaced teeth Hearing loss Lip deformities Nasal deformities Recurrent ear infections Speech difficulties Hypernasal voice quality Nasal regurgitation of food or drink Other: What is your child s reaction to the cleft lip/palate? Has there been any significant change in the last six months? If so, what? How well is your child understood by : (i.e., what percentage of the time) Mom: Dad: Younger siblings: Older siblings: Other Children: Extended family: Unfamiliar adults: Describe what it is like to have a conversation with your child: Any previous assessments? Y N Where? By whom? What kind? Which tests were given? What were the results? Any previous speech therapy? Y N Where? With whom?
4 Related Medical and Developmental History How many pregnancies has the mother had? Which pregnancy was this child? Mother s age at the time of this pregnancy: Has the mother had any miscarriages? Stillbirths? If yes, which pregnancy? If yes, which pregnancy? Did the mother have any of the following during this pregnancy? German measles Toxemia Anemia Kidney infection Accidents/injuries (describe) Other maternal medical condition (describe) What medical management (drugs during labor and delivery) did the mother receive? Did mother take prescription and/or nonprescription medication during this pregnancy? If yes, please list medications Was your child full-term? premature? birth weight: Length of hard labor: Was the delivery: Normal? Cesarean? Breech? Were forceps used? Any birth injuries? (Circle one) Has there been any history of birth defects in your family? Yes No If yes please describe? With what family relation did it occur?
5 Did any other syndromes or illness co-occur with your child s cleft lip/palate? If so, please describe. Does your child have any allergies, including any food allergies? If so what are they? (Circle one) Is your child taking any over the counter medications at this time? Yes No If yes, which ones and for what? _ Are immunizations current? Y N Current general health? Age when child: (If you can t remember specific time, please indicate if it occurred at the expected time or was delayed) sat up crawled walked toilet trained dressed self tied shoes fed self independently Attention span for self- directed activities: Does your child play with others? Who? Cry appropriately? Laugh? Smile? Make wants known? How? Does your child show unusual behavior (explain)? Speech and Language Language(s) spoken in the home: Age when child spoke first word: combined words: spoke in sentence:
6 Which sounds (if any) are incorrect? Does your child have any difficulty understanding you (describe)? Does your child have any difficulty following directions (describe)? Any speech or hearing problems in the immediate or extended family (explain)? Social Development Names and ages of siblings: Other adults living in the home: Number of regular playmates: Ages: Genders: How does your child handle frustration? What motivates your child the most? School History What school does your child attend: What grade is your child in? How does your child s teacher describe his/her performance? Has the teacher expressed any concern? If so, what? Is there anything else you would like us to know about your child?
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a guide to understanding pierre robin sequence
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