1 Maguire Rd

Lexington, Ma 02421

781-860-1700

Transition/Adult Patient Information Form

Age 14 and Above

You may download the Transition/Adult Patient Information Form and enter your responses electronically. You may also print the form and enter handwritten responses.

You may either email the completed form to us at or mail the completed form to our address provided on the form itself. Once we receive the completed Patient Information Form, we will call you within 2 weeksto either schedule an appointment or refer you to another provider(s) that may better serve your needs. Please remember that the Lurie Center is scheduling new patient appointments out 6 to 9 months for most services.

Before you complete the form:

  • Since this initial form is so lengthy, we recommend that you confirm with your insurance company that the providers of the MGPO (Mass General Physician Organization) are covered through your insurance. Please also confirm that there are no exclusions for autism spectrum disorders.

Section 1. Demographic Information
Patient Name:
Date of Birth: / Age:
Home Street Address:
City/State: / Zip Code:
Guardianship Status: Self ParentOther:
Parent/Guardian Name(s):
Address (if different than above):
Preferred Phone: / Alternate Phone:
Email Address:
Parents’ marital status: Single Married Divorced Other (please explain)
Patient Living Situation: Family Home Group Home and agency ResidentialSchool
Adult Foster Care Supported Apartment
Name of Support Agency (if applicable):
Agency Contact Person:
Agency Fax: / Phone: / Email
Employer: None
Day Program: None
Patient’s marital status: Single Married Divorced Other (please explain)
Has the patient ever been in trouble with the police? Yes No
If yes, please describe
Family Information:
Relation / Name / Age / Level of Education / Occupation / Lives with Patient (Yes or No)
Parent / Yes No
Parent / Yes No
Sibling(s) / Yes No
Yes No
Yes No
Yes No
Section 2. Primary Concerns and Diagnostic History
What are your major concerns and goals for today’s visit?
Any previous neurological, developmental, autism spectrum or any mental health diagnoses?
Yes No
If yes, please list diagnoses below:
Previous Diagnoses: / Date of Diagnosis: / Diagnosed by:
1.
2.
3.
4.
5.
6.
7.
What other medical providers does the patient see outside the LurieCenter?
Section 3. Pregnancy/Birth History
If patient was adopted and information on the pregnancy or birth history is not available, please check this box and proceed to Section 4.
History of infertility? Yes No
Hormone treatment or birth control use prior to pregnancy? Yes No
Conception assisted?Yes No
If yes, check all that apply:
Artificial Insemination In vitro fertilization Fertility drug
If fertility drug used, please list name of medication(s):
During pregnancy: / Excessive nausea/vomiting? Yes No
Gain of more than 35 lbs? Yes No / Gain of less than 10 pounds? YesNo
Special diet? Yes No If yes, reason:
RH incompatibility? Yes No If yes, treated with Rhogam? Yes No
Alcoholic beverages consumed during pregnancy? Yes No
If yes, please list alcohol type/frequency/number of drinks per day:
Recreational drug use during pregnancy? Yes No
If yes, please list types of drugs other than alcohol:
Cigarette smoking during pregnancy? Yes No
Prenatal vitamins during pregnancy? Yes No
Medications other than vitamins during pregnancy? Yes No
If yes, please list:
High blood pressure during pregnancy? Yes No
Severe headaches during pregnancy? Yes No
Spotting or bleeding during pregnancy? Yes No
Physical or emotional trauma to the mother during pregnancy? Yes No
If yes, please explain:
Ultrasounds during pregnancy? Yes No
If yes, how many:
Amniocentesis? Yes No
Premature labor or concerns about premature labor? Yes No
If yes, how was it treated?
Any significant illnesses during pregnancy? Yes No
If yes, please specify:
Any significant infections during pregnancy? Yes No
If yes, please specify:
Depression during pregnancy? Yes No
Were the baby’s movements different than in other pregnancies? NA Yes No
If yes, please explain:
Length of pregnancy:
Length of labor:
Induced? Yes No
Anesthesia?Yes No
Birth was Vaginal Cesarean Breech Twins or multiple births
If Cesarean, please explain:
Were forceps used? Yes No
Did the mother have complications? Yes No
If yes, please specify:
Section 4. Newborn History
Did the baby go home from hospital with the mother in a typical amount of time? Yes No
If no, please specify:
Check any of the following the baby experienced during the first month of life:
excessive crying / severe diarrhea / skin rash / jaundice
nursing/feeding difficulty / injury / infection / convulsions/seizures
cyanosis (blue baby) / other; if other, please describe:
What was the child like to care for as an infant?
Section 5. Developmental History
A) Motor Skills
Do you remember any specific or generalized delays in motor development? Yes No
If yes, please describe:
State any concerns you have regarding the patient’s strength or motor coordination skills:
Does the patient fatigue easily? Yes No
Does the patient use any special equipment (wheel chair, braces, etc.)? Yes No
If yes, please specify:
B) Communication
Age when patient began to talk:
Did patient begin to use words and then stop? Yes No If yes, at what age stopped?
How does the patient mainly communicate? Please check all that apply below:
crying/vocalizing / single words / typing / pulls person to object of interest
gestures / signing / babbling / two-word phrases
sentences / rote phrases / electronic device / making up words
Do you have any concerns about your child’s speech/ language? Yes No
If yes, please specify:
Please list all languages spoken at home:
C) Sensory
Is the patient sensitive to sound?
normal overly sensitive under sensitive other, please explain:
Is the patient sensitive to odors?
normal overly sensitive under sensitive other, please explain:
Is the patient sensitive to tough/clothing?
normal overly sensitive under sensitive other, please explain:
Is the patient sensitive to lights?
normal overly sensitive under sensitive other, please explain:
Does the patient seek sensory input/stimulation? Yes No
If yes, please explain:
D) Feeding and Nutrition
Does the patient eat too quickly? / Yes No
Do you think the patient may have acid reflux? / Yes No
Does the patient regurgitate frequently? / Yes No
Any dietary problems?
Any concerns about patient’s nutritional status or weight?
E) Self-Help Skills
Please check whether the patient has the listed self-help skills. If yes, list age at which skill first developed.
toilet trained (bladder)? / not yet / If yes, age: / button clothes? / not yet / If yes, age:
toilet trained (bowel)? / not yet / If yes, age: / tie shoelaces? / not yet / If yes, age:
able to dress self? / not yet / If yes, age: / bathe/shower? / not yet / If yes, age:
able to undress self? / not yet / If yes, age: / choose suitable clothes? / not yet / If yes, age:
Do you have any specific concerns about patient’s self-help skills? Yes No
If yes, please explain:
F) Independent Skills
Please check whether the patient has the listed independent skills. If yes, list age at which skill first developed.
manages transportation? / not yet / If yes, age: / able to make change? / not yet / If yes, age:
has drivers license? / not yet / If yes, age: / has concept of money / not yet / If yes, age:
able to manage money independently? / not yet / If yes, age:
Do you have any specific concerns about patient’s independentliving skills? Yes No
If yes, please explain:
G) Social/Emotional Growth
Has the patient ever done any of the following? Please check all that apply.
preferring to be alone / unusually inactive
difficulty with opposite sex / bed wetting
nail biting / masturbating
destructiveness / self-injurious
repetitive hand or body movements / repetitive use of language
difficulty with siblings/peers / preoccupations
difficulty sleeping / repetitive/play
Are there any preoccupations or compulsions? Please describe:
What are the patient’s favorite activities?
Does the patient have meaningful friendships? somenone one or two many
Are the patient’s friends: older younger same age mixed ages
Section 6. Childhood Medical History
Check any of the following conditions the patient has experienced and list their age at time of event and any complications:
Disease/Problem / Age / If complications please explain?
Measles, Mumps, or Rubella
Chickenpox
Frequent infections (ex. Strep throat)
Meningitis/Encephalitis
Seizures/convulsion
Fainting spells
Headaches/migraine
Difficulties sleeping or sleep disorder
Asthma
Acid reflux
Constipation/diarrhea
Frequent falls
Accidents/head trauma
Unusual severity of common illness
Ear infections
Hearing problems
Constipation/diarrhea
Vaccine reaction
Rashes
Visual Problems
Head injury/ Traumatic brain injury
Loss of consciousness
Other
Has the patient had any hospitalizations? Yes No
If yes, please list date, reason and approximate number of days of hospitalization in the table below:
Date / Reason / Estimated Days
Has the patient had any surgical procedures? Yes No
If yes, please list approximate date and reason for surgeries in the table below:
Date / Reason for Surgery
Please check any medical diagnostic tests the patient has completed:
MRI EEG CT Scan Blood/Lab work Genetic work-up Other, specify:
Results of the above testing:
Does the patient have any food allergies? Yes No
If yes, please list:
Does the patient have any special dietary restrictions? Yes No
If yes, please list:
Is the patient taking any vitamins and supplements? Yes No
If yes, please list:
Please list all current and past medications and their dosages:
Medication / Dose / Current / Past
Does the patient have any medication allergies? Yes No
If yes, please list:
Does the patient have any side effects to medications? Yes No
If yes, please list:
Has the patient had a vision exam? Yes No
If yes, when and what results?
Has the patient had a hearing test? Yes No
If yes, when and what results?
Are the patient’s immunizations up to date? Yes No
Does the patient have regular dental visits? Yes No
Section 7. Family Medical History
If any of the patient’s immediate biological family or relatives has experienced any of the following conditions,
please check the condition, write their relationship to the patient, and provide more details, if possible.
Condition / Relationship to patient / Comments
Seizure disorder
Autism/PDD/Asperger’s
Cerebral palsy
Intellectual disability (Mental retardation)
Language delay/
communication problems
School difficulties
(include grades repeated)
Learning disability
Muscular weakness
Deformities
Multiple Sclerosis
Alcoholism/substance abuse
Emotional/ Psychiatric problems
Other serious illness
High blood pressure
Heart disease
High cholesterol
Stroke
Diabetes
Cancer
Thyroid problems
Asthma
Anxiety Disorders
Depression
Anxiety
Bipolar Disorders
Schizophrenia/Psychosis
Attention-Deficit Hyperactivity Dx (ADHD/ADD)
Lupus
Rheumatoid Arthritis
Crohn’s Disease
Ulcerative Colitis
Psoriasis
Genetic Disorder
8. Educational/Employment
Last school attended:
Current situation: School College Employed Day Program Add comments:
Please check any services the patient is currently receiving or has received:
Therapy / In school / Out of School / Currently / Previously
Speech-Language Therapy
Physical Therapy
Occupational Therapy
Counseling
Resource Room
Summer Services
Other:
Diagnostic Testing(Please list below the most recent school tests, CORE/Team evaluations, etc.):
Date Completed / Type of Test / Conclusions/Recommendations
What supports are currently in place?
Section 9. Please share any additional concerns or questions that you have:

The Lurie Center, as part of Massachusetts General Hospital and Harvard Medical School, is committed to the missions of clinical care, research and education. May our research staff contact you about educational or research opportunities at the Lurie Center?

Yes No

Name of person completing this form / Relationship to patient / Date
Attach your completed form to an email and send to:
/ Or mail to:
New Appointments
Lurie Center
1 Maguire Road
Lexington, Massachusetts 02421
Additional Information
  • For caregivers of patients age 18 or older, please send either a copy documenting legal guardianship or send a completed Authorization for Release of Protected or Privileged Health Information.
  • Once we receive your completed New Patient Information Form, we will contact you within 2 weeksto either schedule an appointment or refer you to another provider(s) that may better serve your needs.Please remember the Lurie Center
is booking new patient appointments out 6 to 9 months for many services.
  • If you have any questions, please call 781.860.1708 and speak to, Maggie Pagan. You may also contact us via email at .
.

LurieCenter for Autism/1 Maguire Road, Lexington, MA02421

Phone 781.860.1700/Fax 781.860.1766

Page 1 of 11 Form Version March 2015