Appendix 1.

Patient Questionnaire.

Name:
Date of Birth:
Home Phone:
Cell Phone:
Other Phone:
Grandparent phone:
E-mail address:
City, State:
Referred by:
Pediatrician:	Phone:
Physical Therapist:	Phone:
Physiatrist:	Phone:
Neurologist:	Phone:
Is the child able to walk? If so, can the child walk 20 feet or more in a clinic with or without equipment?
Can the child stand for one minute without assistance?
Does the child use a wheelchair for mobility? NoYes (circle)
Today’s Date:
What name does child go by? What is the child’s overall condition? (example: cerebral palsy, anoxic brain injury)
Reason for seeing Dr. Yngve (example: “tight hamstrings,” “walking on toes”)
History of Present Illness (Provide a brief description of the child’s current problem you are seeking medical attention for):
Are there any current issues the child is experiencing?
Child’s favorite thing (What does he/she like to play with, what interests them?)
Birth history (How many weeks was the baby born at? Was there any problem when the baby was in the womb?)
Brain history (Does the child have cerebral palsy or some other brain disorder? Was this diagnosed with an MRI?):
Any history of Botox injections? (if so, how long have they been getting them and what part of the body was injected?)
Does the child have Ankle Foot Orthoses (AFO’s)? If so, who provides the Orthoses? Assistive devices (example walker; crutches; wheelchair; gait trainer?) Physical Therapy (how many times per week?)
Language ability (Is the child able to communicate fully with you? Are they able to understand what you say? Are they able to show you when they are in pain?)
Pain Questions: Rate your child’s pain in the last week on a scale of 0–10. Where was the pain? Child’s rating? (put n/a if not possible)
PODCI Pain questions:29 (For the following questions put today’s date before the correct response) -During the last week how much of the time did your child feel sick and tired? ________ most ________some ________a little ________ none -During the last week how much of the time did pain or discomfort interfere with your child’s activities? ________ most ________some ________a little ________ none -How much pain has your child had during the last week? _______ none _______ very mild _______ mild _______ moderate _______ severe _______ very severe -During the last week how much did pain interfere with your child’s normal activities including at home, outside of the home and at school? ______ not at all ______ a little bit ______ moderately ______ quite a bit ______ extremely