Birth History:
...
Health & Well-Being
Health Behaviours
Click Health Behaviors in the Health & Well-Being section.
Type in a response for Birth weight (in pounds) or select ‘Don’t Know’ if appropriate.
Select Vaginal or C-Section for Delivery method or select ‘Don’t Know’ if appropriate.Select At term or Early for when the Baby was born or select ‘Don’t Know’ if appropriate. If ‘Early’ is selected, type in a response for ‘Indicate at how many weeks gestation if the baby was born early. Otherwise leave blank. Numeric input only’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘Did the baby have any problems right after birth’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘Was there any illness or problem with the mom’s pregnancy’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘During the pregnancy did the mother smoke’ or select ‘Don’t Know’ if appropriate. If Yes, type in a response for ‘what did the mother smoke’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘During the pregnancy did the mother drink alcohol’ or select ‘Don’t Know’ if appropriate. If Yes, type in a response for ‘when during the pregnancy did she drink’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘During the pregnancy did the mother use drugs/medicines’ or select ‘Don’t Know’ if appropriate.
Select Yes or No for ‘Did the baby go home with mother from the hospital’, or select ‘Don’t Know’ if appropriate.
Click Save.
...
Health Behaviors:
Click Health Behaviors in the Health & Well-Being section.
Select a response from the Never – Always scale for ‘How often can you/your child depend on having an adult to talk to’.
Select a response from the Never – Always scale for ‘If a problem or emergency arises, how often can you/your child depend on an adult to turn to for help and support’.
Select Yes or No for ‘… seen any non-violent crime in your/their neighborhood, such as someone selling drugs or stealing’.
Select Yes or No for ‘… seen any violent crimes taking place in your/their neighborhood, such as someone being beaten up’.
Select Yes or No for ‘… known someone other than yourself/themselves who was a victim of a violent crime in your/their neighborhood’.
Select Yes or No for ‘… been a victim of a violent crime in your/their neighborhood’.
Select Yes or No for ‘… been bullied at school (including cyberbullying) or in your/their neighborhood’.
Select Yes or No for ‘… experienced on-line bullying or threats (cyber-bullying)’.
10. Click Save.
...
‘In the past three months have you smoked cigarettes or used any form of tobacco (e.g. chew, dip, cigars, hookah, and/or e-cigarettes)?’
Select a response for ‘Have you ever ridden in a car driven by someone (including yourself) that was high or was using alcohol or drugs?’
Select a response for ‘Does anyone in your home take opioids for an ongoing medical condition? (OxyContin, Hydrocodone, Codeine)’
Select Yes or No for ‘Do you lock your opioid medications in a medicine cabinet or other locked location?’
Select Yes or No for ‘Do you have a smoke detector in your home?’
Select Yes or No for ‘Do you have gas heating or appliances in your home?’
Select Yes or No for 'Do you have a carbon monoxide detector in your home?'
Click Save.
...
Caregiver
Click Caregiver in the Health & Well-Being section.
Select Yes or No for ‘Do you /Does your child have a caregiver that comes into the home, because of a health care problem, to provide you with assistance?’
Select Relative, Friend, or Agency for ‘Is caregiver a relative, friend, or from an agency?’
Type in a response for Caregiver/Agency Name.
Type in a number for Caregiver/Agency phone number.
Type in a response for Caregiver/Agency Specialty.
Select Per Day or Per Week for ‘ How ‘How many hours per day/week does caregiver come into your home?’. Then, type in a response.
Type in a response for ‘What items does your caregiver help with?’
Select Yes or No for ‘Do you /Does your child need more help than you are receiving?’
If Yes, type in an explanation.
Click Save.
...
ADL / IADL
...
Click ADL / IADL in the Health & Well-Being section.
Select a response from the Independent – Cannot Do scale for Bathing.
Select Yes or No in the Receiving Help column for Bathing.
Select a response from the Independent – Cannot Do scale for Dressing.
Select Yes or No in the Receiving Help column for Dressing.
Select a response from the Independent – Cannot Do scale for Grooming.
Select Yes or No in the Receiving Help column for Grooming.
Select a response from the Independent – Cannot Do scale for Mouth care.
Select Yes or No in the Receiving Help column for Mouth care.
Select a response from the Independent – Cannot Do scale for Toileting.
Select Yes or No in the Receiving Help column for Toileting.
Select a response from the Independent – Cannot Do scale for Transferring bed/chair.
Select Yes or No in the Receiving Help column for Transferring bed/chair.
Select a response from the Independent – Cannot Do scale for Walking.
Select Yes or No in the Receiving Help column for Walking.
Select a response from the Independent – Cannot Do scale for Climbing stairs.
Select Yes or No in the Receiving Help column for Climbing stairs.
Select a response from the Independent – Cannot Do scale for Eating.
Select Yes or No in the Receiving Help column for Eating.
Select a response from the Independent – Cannot Do scale for Shopping.
Select Yes or No in the Receiving Help column for Shopping.
Select a response from the Independent – Cannot Do scale for CookingManaging medications.
Select Yes or No in the Receiving Help column for Managing medications.
Select a response from the Independent – Cannot Do scale for Using phone book/looking up numbers.
Select Yes or No in the Receiving Help column for Using a phone book/looking up numbers.
Select a response from the Independent – Cannot Do scale for Doing housework.
Select Yes or No in the Receiving Help column for Doing housework.
Select a response from the Independent – Cannot Do scale for Doing laundry.
Select Yes or No in the Receiving Help column for Doing laundry.
Select a response from the Independent – Cannot Do scale for Driving or using public transportation.
Select Yes or No in the Receiving Help column for Driving or using public transportation.
Select a response from the Independent – Cannot Do scale for Managing finances.
Select Yes or No in the Receiving Help column for
Managing finances.
Click Save.
...
Sleep
...
Click Sleep in the Health & Well-Being section.
Type in a response for ‘On average how many hours of sleep do you get in a 24-hour period’.
Select Yes or No for ‘Do you feel your sleep is restful?’
...
...
Employment
Click Employment in the Health & Well-Being section.
Select a response for ‘What is your current type of employment?’ from the ‘Employed – Full time’ – ‘Not in labor force’ scale. Select ‘Prefer not to answer’ if appropriate.
If Not Employed, select a response(s) for question 1a.
Select all that apply.
If Employed, type in a response for question 1b.
Click Save.
...
Development:
Click Development in the Health & Well-Being section.
Select Yes or No for ‘Are you concerned about your/your child's physical development’. If Yes, type in an explanation.
Select Yes or No for ‘Are you concerned about your/your child's mental or emotional development’. If Yes, type in an explanation.
Select Yes or No for ‘Are you/Is your child having problems with behavior in school?’ If Yes, type in an explanation.
Select Yes or No for ‘Have you/Has your child failed or repeated a grade?’ If Yes, type in an explanation.
Select Yes or No for ‘Are you/Is your child having academic problems in school?’ If Yes, type in an explanation.
Select Yes or No for ‘Have you/Has your child failed or repeated a grade?’ If Yes, type in an explanation.
Select Yes or No for ‘Are you/Is your child in special resource classes/special education?’ If Yes, type in an explanation.
Click Save.
...
D.M.E.
Click D.M.E. in the Health & Well-Being section.
Select a response from the Have – Don’t Need scale for any of the listed medical equipment (questions 1-23).a.
Click the teal, column-heading buttons in order to select the same response for questions 1-23.
The select-all functionality can be used as a starting point if nearly all the answers will be the same.
Select Yes or No for ‘Do you have other adaptive equipment that is not listed above?’
If Yes, type in
a description.
Select Yes or No for ‘Do you want other adaptive equipment that is not listed above?’
If Yes, type in
a description.
Click Save.
...
Legal
...
Click Legal in the Health & Well-Being section.
Select Yes or No for ‘Do you /Does your child have an advance directive and/or living will?’. Select ‘Don’t Know’ if appropriate.
If Yes, select Yes or No for ‘Do you
have a copy of your advance directive and/or living will to put in your record?’
Select Yes or No for ‘Do you /Does your child have a psychiatric advance directive?’. Select ‘Don’t Know’ if appropriate.
If Yes, select Yes or No for ‘Do you
have a copy of your advance directive and/or living will to put in your record?’
Select Yes or No for ‘Have you /Has your child given Power of Attorney (POA) to someone?’.
If Yes, type in a response for whom.
If Yes, select Yes or No for ‘Do you
have a copy of your POA to put in your record
...
?’
Select a response for ‘In the past six months, have you been arrested?’
Select a response for ‘In the past six months, were you the victim of any violent crimes, such as assault, rape, mugging, or robbery?’
...
Safety/Injuries
...
Click Safety/Injuries in the Health & Well-Being section.
Select Yes or No for ‘Have 'Do you /Has your child ever been physically, sexually, or emotionally abused’.have a gun/firearm in the home?'
If yes, answer 1a and 1b
Select Yes or No for ‘Have you/Has your child ever been in foster care, group home(s), or been homeless’.‘During the past 12 months did you smoke any marijuana or hashish?’
Select Yes or No for ‘Have you/Has your child ever been in jail or in a detention center.
Select a response from the None – More than 1-time scale for ‘Been out of your/their parent's or caregiver's control so that the police needed to get involved’.
Select a response from the None – More than 1-time scale for ‘Purposefully damaged or destroyed (other than fire) property that did not belong to you/them’.
Select a response from the None – More than 1-time scale for ‘Taken something from a store without paying for it’.
Select a response from the None – More than 1-time scale for ‘Hit someone or been in a physical fight’.
Select a response from the None – More than 1-time scale for ‘Gotten a ticket or citation for a traffic violation (driving too fast, driving through a red light, etc.)’.‘During the past 12 months did you use anything else to get high (includes illegal drugs, over-the-counter and prescription drugs, and things you sniff or huff)?'
If Yes was chosen for either question regarding the use of drugs, answer the following. Otherwise, leave blank.
Select Yes or No for ‘Do you use drugs to relax, feel better about yourself, or fit in?’
Select Yes or No for ‘Do you ever use drugs while you're by yourself, alone?’
Select Yes or No for ‘Have you ever gotten into trouble while you were using drugs?’
Select Yes or No for ‘Do
...
you ever forget things you did while using drugs?’
Select Yes or No for ‘Does your family or friends ever tell you that you should cut down on your drug use?’
...
Future Plans
Click Future Plans in the Health & Well-Being section.
Type in a response for ‘What are your/your child's future plans for additional schooling, having a family, and career goals?’
...
?’
...
Financial Support
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover food?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover clothing?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover housing?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover traveling around to get things, shopping, medical appointments, or visiting friends or relatives?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover social activities like movies or eating in restaurants?’
Select Yes or No for ‘In the past six months, did you generally have enough money each month to cover Heating, air conditioning, water, electricity, gas?’
Select Yes or No for ‘Have you received mental health or developmental disability services?’
Select Yes or No for ‘Do you have questions you would like to discuss with your provider?’
Select Yes or No for ‘Do you know what benefits are available to you?’
Select Yes or No for ‘Do you feel your benefits meet your needs?’
...