UWMC High Risk Infant Follow-up Clinic

Health Status Report

Date:______Patient Name:______Medical Record Number:______

Section A: ID and Risk Factors

1. Birth Date:______2. BirthHospital: ______

3. Gestational Age at Birth:____wks____days4.  Male Female

5. Birth Weight:______Grams

6. Referral Source: UW NICU Parents  Primary Care Provider  Legal CaseOther:______

7. Risk Factor(s): PrematurityPrenatal Drug Exposure Other ______

Section B: Living Situation

  1. Home Child Resides: Parent/Family member Foster Care Adoptive Parents  Chronic Care Facility
  2. Caregiver(s): Single Parent Single parent extended family Institutional

Check ()only one. Two parent Two parent extended family

  1. Primary Caregiver Grade 8 or less Some college/university Not applicable

Education: Some high school College/university graduate Unknown

Check ()only one. High school graduate/GED

Section C: Support After Discharge
  1. Medical Support after ultimate NICUdischarge:
Check () all that apply
1. Tracheostomy
2. Ventilator
3. Oxygen
4. Gastrostomy
5. Nasogastric Feeds
6. Apnea or Cardio-respiratory Monitor
7. None
8. Unsure
9. Shunt (VP, VA) / Section D: Medical Rehospitalizations & Surgeries
  1. Medical rehospitalizations since last visit:
 Yes  No  Unsure
Number of
If yes, Category:Check () all that apply Admissions
 a. Respiratory Illness ______
 b. Nutrition/Failure to Thrive ______
 c. Seizure Disorder ______
 d. Shunt Complication ______
 e. GERD (Reflux) ______
f. Infections (not respiratory or shunt infections)
 1. Meningitis ______
 2. Urinary Tract Infection ______
 3. Gastrointestinal Infection ______
 4. Other Infection:______
(specify)
 g. Other Medical Rehospitalization Category:
(specify)______
  1. Surgical Procedures After Discharge
 Yes  No  Unsure
(specify)______
______


Developmental Status Report

Section E: Growth Parameters

  1. Corrected Age (use for growth parameters) : ______months ______days
  2. Weight: ______.______kg3. Height: ______.___ cm4. Head Circumference: ______.___ cm

Percentiles Percentiles Percentiles

 <5%  <5%  <5%

5% 5% 5%

5-25% 5-25% 5-25%

25%25%25%

25-50% 25-50%25-50%

50% 50% 50%

50-75% 50-75% 50-75%

75%75%75%

75-95%75-95%75-95%

95%95%95%

>95%>95%>95%

Section F: Vision & Hearing

  1. Clinical appraisal of Blindness One Eye Both Eyes Not Blind Unsure
  2. Prescription Glasses Yes No
  3. Hearing Impairment Today: One Ear Both Ears Not Impaired Unsure  Not Tested
  4. Type of Hearing Impairment: Conductive Sensorineural Combined
  5. Amplification: Yes No
  6. Clinical Appraisal of long-termHearing Impairment: One Ear Both Ears Not Impaired Unsure

Section G: Cerebral Palsy

  1. Cerebral Palsy Yes No

a. Type: Spastic Athetoid Mixed

b.Distribution: Diplegia Hemiplegia Quadriplegia Triplegia

  1. Muscle Tone:Hypotonia Hypertonia Both (hypotonia & hypertonia)Normal

Section H: Developmental TestingIndex score for Adjusted Age:

  1. MAI (Movement Assessment of Infants)Risk Score______
  2. Bayley Scales of Infant Development: Edition 2MDI ______PDI ______

[Circle edition of test used] Edition 3Cognitive_____Language_____Motor_____

  1. DAS (Differential Ability Scale)Score: _____
  2. Stanford-Binet Score: _____
  3. PPVT (Peabody Picture Vocabulary Test)Score: _____
  4. VMI (Visual Motor Integration)Score: _____
  5. WPPSI-IIIFull Scale IQ:______Verbal IQ: ______Performance IQ:______Processing Speed:______
  6. WISC-IVFull Scale:______Verbal Comprehension: ______Perceptual Reasoning:______Working Memory:_____ Processing Speed:______

Section I: Overall Clinical Appraisal of Developmental Function

  1. Clinical Appraisal of Cognitive Function:Normal BorderlineDelayed
  2. Clinical Appraisal ofMotor Function:Normal BorderlineDelayed

UWMC HRIF Clinic Data Forms Version 1.65/21/2008