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 CaseOther:______
7. Risk Factor(s): PrematurityPrenatal Drug Exposure Other ______
Section B: Living Situation
- Home Child Resides: Parent/Family member Foster Care Adoptive Parents Chronic Care Facility
- Caregiver(s): Single Parent Single parent extended family Institutional
Check ()only one. Two parent Two parent extended family
- 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- Medical Support after ultimate NICUdischarge:
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
- Medical rehospitalizations since last visit:
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)______
- Surgical Procedures After Discharge
(specify)______
______
Developmental Status Report
Section E: Growth Parameters
- Corrected Age (use for growth parameters) : ______months ______days
- 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
- Clinical appraisal of Blindness One Eye Both Eyes Not Blind Unsure
- Prescription Glasses Yes No
- Hearing Impairment Today: One Ear Both Ears Not Impaired Unsure Not Tested
- Type of Hearing Impairment: Conductive Sensorineural Combined
- Amplification: Yes No
- Clinical Appraisal of long-termHearing Impairment: One Ear Both Ears Not Impaired Unsure
Section G: Cerebral Palsy
- Cerebral Palsy Yes No
a. Type: Spastic Athetoid Mixed
b.Distribution: Diplegia Hemiplegia Quadriplegia Triplegia
- Muscle Tone:Hypotonia Hypertonia Both (hypotonia & hypertonia)Normal
Section H: Developmental TestingIndex score for Adjusted Age:
- MAI (Movement Assessment of Infants)Risk Score______
- Bayley Scales of Infant Development: Edition 2MDI ______PDI ______
[Circle edition of test used] Edition 3Cognitive_____Language_____Motor_____
- DAS (Differential Ability Scale)Score: _____
- Stanford-Binet Score: _____
- PPVT (Peabody Picture Vocabulary Test)Score: _____
- VMI (Visual Motor Integration)Score: _____
- WPPSI-IIIFull Scale IQ:______Verbal IQ: ______Performance IQ:______Processing Speed:______
- WISC-IVFull Scale:______Verbal Comprehension: ______Perceptual Reasoning:______Working Memory:_____ Processing Speed:______
Section I: Overall Clinical Appraisal of Developmental Function
- Clinical Appraisal of Cognitive Function:Normal BorderlineDelayed
- Clinical Appraisal ofMotor Function:Normal BorderlineDelayed
UWMC HRIF Clinic Data Forms Version 1.65/21/2008