New Patient Evaluation Packet

Thank you for spending the time to answer the comprehensive set of questions in this New Patient Evaluation Packet!

The information that you provided is very valuable because you know your child best.
I appreciate your input and am looking forward to working with you and your child to help with optimizing their development and/or behavior in a positive way.
Please contact me if you have any questions/concerns.
HIPAA Secure Email: Samantha.Cohen@hushmail.com

SCDBP

Information and Instructions for completing the New Patient Evaluation Packet:

*Please read the instructions prior to answering the questions below.

1) This is a comprehensive questionnaire about your child/adolescent's development and behavior. *Please note that the term "your child" is used as a general term below to refer to the patient for whom you are completing this packet regardless of their age and/or biological relationship to you.

2) It may take up to 60* minutes to answer all of the questions.

3) Plan ahead so that you have plenty of time to complete the packet in one sitting. *Please note: Your answers will NOT be saved and sent to Dr. Cohen until you complete the required questions and click submit at the bottom of the packet.

4) Some of questions require that you type your answers.

5) Many of the questions have check boxes for possible answer options. Please check all boxes that apply.

6) Questions with check boxes also have a space below were you can share additional information about the answers you chose and/or any additional comments.

7) Questions with a red asterisk are required. If the question does not apply to your child please check the box next to n/a.

8) If you already answered some of these questions in the Social History portion of the Health History Form in the patient portal you can select the check box next to n/a and put in the comments "see responses in pt portal".

9) Please contact Dr. Cohen's office if you have any questions about the form.

10) Please remember to click the "submit" button at the bottom of the packet.

Child/Adolescent Demographic Information

Full Name

Current Age

(Please give in months or years and months)

Race/Ethnicity: Please check all that apply.

African American

Asian American

Caucasian

Hispanic

Latinx

Native American

Pacific Islander

Other

Prefer not to share

Additional home address (if different than the primary address given during registration):

Please include the street, city, state and zip code. If your child does not live in any other homes, you can enter "n/a"

Please list all of the people that live at home with your child and the percentage of time spent in each home (as applicable)

For example: "Mom & Dad; 100%" or "50% with Mom, younger brother, and older sister & 50% with Dad, younger brother, and older sister".

Reason for Evaluation:

Please describe your main concerns regarding your child:

At what age were these concerns first noticed?

Prior evaluations and/or supports:

Has your child received any prior evaluations and/or supports for these concerns?

Yes

If yes, please list the date of the evaluation, the person and/or organization that completed the evaluation and the results of the evaluation on separate lines below. If no, please write n/a below.

For example: “a) 10/28/2022, Early Start/San Diego Regional Center Evaluation: found to have delays in language and fine motor skills; received speech and occupational therapy until age 3.”

Current Services/Supports:

Comments/additional information:

Goals:

What are your main goals and/or expectations from this evaluation/assessment?

Getting to know your child:

Please share three adjectives that best describe your child?

What are your child’s strengths (i.e. things that your child is good at and/or things that you love about your child)?

Parent/Caregiver's Observations of Their Child's Current Functioning Across Developmental & Behavioral Domains:

Communication:

Comments/additional information:

2) What is your child's Expressive Language Level? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

babbles/vocalizes but no words yet

(i.e. "ba ba ba" or vowel sounds like "ah")

has about ___ words total (such as ...)

Please describe below.

uses a lot of gibberish

(i.e. their own made up language)

mixes real words with gibberish/jargon

puts 2 words together

(i.e. "me up" or "big ball")

speaks in short phrases/sentences

Please describe below.

fluent language skills/able to communicate effectively with others

has advanced language skills for age

Please describe/give examples below.

Comments/additional information:

4) How understandable is your child/the patient’s Speech? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

clear and easily understandable to all

___% understandable to parents

Please describe below.

___% understandable to strangers

Please describe below.

uses mostly word approximations of real words

hard to understand because they use a lot of gibberish/made up language

uses made up words

For example, calls spoons "dippers". Please describe below.

n/a

other

Please describe below.

Comments/additional information:

Nonverbal Communication Skills:

Comments/additional information:

Response to Social Cues:

Comments/additional information:

2) How does your child respond to social smiles from others? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

smiles back when others smile at them

respond to social smiles varies - depends on the person and/or their mood

Please describe below (i.e. returns smiles with parents/close family but not with others such as at the grocery store; only returns social smiles when in a good mood).

does not respond to social smiles

tends to get shy and look away

doesn't notice social smiles from others

other

Please describe below.

unsure

Please describe below.

Comments/additional information:

Social Interactions/Peer Relationships:

Comments/additional information:

2) Does your child have a preference for playing/interact with older, younger or same age peers? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

has had limited opportunities to interact with other children

Please describe below.

has regular opportunities to interact with other children

Please describe below.

same age peers

older peers

younger peers

all ages (no preference)

prefers to interact with adults vs peers

other

Please describe below.

n/a

Comments/additional information:

Play/Leisure/Extracurricular Activities:

Comments/additional information:

5) Does your child engage in Active play/Exercise for at least 60 minutes/day? Please describe the amount of active play/exercise your child gets below. Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

yes

sometimes

unsure

varies depending on the day of the week or season, etc.

Please describe below.

other

Please describe below.

n/a

Please describe below.

no concerns

Comments/additional information:

Behaviors Observed by Parents/Caregivers:

Comments/additional information:

Sensory Interests and/or Sensitivities:

Comments/additional information:

Attention/Activity Level/Impulsivity:

Comments/additional information:

8) If applicable, how would you rate the severity the challenges your child is experiencing currently? What do you observe? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

mild

moderate

severe

unsure

variable

(i.e. the severity changes over the course of the day; depends on what they are doing, etc). Please describe what you observe below.

other

Please describe below.

n/a

no concerns

Comments/additional information:

Safety Concerns:

Comments/additional information:

Anxiety and/or Mood Concerns:

Comments/additional information:

Activities of Daily Living:

Eating:

Comments/additional information:

Hygiene:

3) How does your child do with their overall personal care and hygiene skills? What do you observe? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

needs parent's help/support for all personal care

can do personal care activities independently but requires frequent reminders from parents to start and/or complete tasks

needs help/support from parents for some personal care/hygiene, but can do some things independently

can do most personal care independently but parents still supervise

manages all personal care independently

unsure

other

Please describe below.

n/a

no concerns

Comments/additional information:

6) How does your child do with hair care? What do you observe? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

doesn't like having their hair brushed/combed or styled

has difficulties with tolerating hair cuts

tolerates having hair brushed and cut without problems

independent for hair care

unsure

other

Please describe below.

n/a

no concerns

Comments/additional information:

Sleep:

Comments/additional information:

11) Where does your child sleep? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

starts in own bed but moves to parent(s) bed overnight,

co-sleeps with parent(s) (or other family member - sibling, grandparent, etc.) throughout the night

Please describe below.

sleeps in own crib/toddler bed in parents room

sleeps in own their own bed

has their own bedroom

shares a room with siblings

other

Please describe below.

Comments/additional information:

School History:

If yes, please write the name of the school/program below, as well as any other comments/additional information:

School Information:

*If your child is not yet in school and these questions are not applicable please write or click n/a for the following questions.

2) What grade is your child in?

If not applicable write n/a.

Comments/additional information:

Childcare/Daycare Information:

*If your child is not in childcare or daycare and the following questions are not applicable please write or click n/a for the following questions.

1) What is the name of the childcare/daycare program that your child attends?

Before/after school programs can be included here. Please write n/a if not applicable.

2) What type of child care/daycare setting is your child in?

center based

home based/in-home

other

n/a

3) What is the age range of the other children at your child's childcare/daycare program? Select all that apply. Please add additional comments in the text box below to clarify or further describe if desired.

younger

older

same age

mixed - some older and some younger

unsure

other

Please describe below.

n/a

Please describe below.

Comments/additional information:

Other:

If desired, please feel free to provide any additional comments or information that wasn't captured above:

Thank you for spending the time to complete this comprehensive intake questionnaire! The information that you provided is very valuable because you know your child best. I appreciate your input and am looking forward to working with you and your child to help with optimizing their development and/or behavior in a positive way.

Your information will be encrypted.

Thank you for spending the time to answer the comprehensive set of questions in this New Patient Evaluation Packet!

The information that you provided is very valuable because you know your child best.
I appreciate your input and am looking forward to working with you and your child to help with optimizing their development and/or behavior in a positive way.
Please contact me if you have any questions/concerns.
HIPAA Secure Email: Samantha.Cohen@hushmail.com

Dr. Samantha Cohen

Developmental Behavioral Pediatrician , and President/CEO of Samantha Cohen, MD, Inc.

A Developmental Behavioral Pediatrics Private Practice

619-320-8696
www.scdbp.com
3405 Kenyon Street, Suite 210 , San Diego, California, 92110, United States