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This registration form is to be printed out and mailed or can be copied to a Word processing program, filled out and recopied to be sent through Email. You cannot fill in the blanks and email directly -sorry.
Please check all items that best describe your child.
Mobility:
(___)Normal for age (___) Walks independently
(___) Walks with crutches
(___)Walker
(___)Crawls
(___)Bears weight
Toilet Skills: (___) Normal for age (___) In Diapers (___) Only at night (___) Catheterized
Vision: (___) Normal (___) Impaired (___) Blind(___) Sees light (___) Contact Lenses
Speech:
(___) Normal for Age (___) Difficult to understand (___)Nonverbal Communication
Diet/Eating Skills:
(___) Normal for age (___) Regular diet (___) Special diet
Hearing:
(___)Normal (___) Impaired (___) Deaf
(___) Reads Lips
Behavior:
(___) Typical for age (___) Hyperactive (___) Overly Affectionate (___) Passive
Special conditions/Equipment:
Hospitalizations/Surgeries: ( related to your child's disability)
List Hospital and date.
________________________________________________________________(___)Good (___) Bad
________________________________________________________________(___)Good (___) Bad
________________________________________________________________(___)Good (___) Bad
Number of Children:
(___) Living (___) Miscarriage(s) (___) Stillborn (___) Died (___)Twins (___)Triples (___)Quadruplets (___) Adopted (___) Foster Other:____________________________________________
Ethnic Background:
(___) White (___) Asian American (___) Native American (___) Hispanic
Languages Spoken Fluently (other than English)____________________________
Could you be a MUMS' hospital volunteer and help a parent in MUMS whose child
needs to be or is hospitalized by visiting them at the hospital ? (___) YES (___) NO (___) could call them.
Which Hospitals?:___________________________________________________________
I heard about MUMS from:______________________________________________________
Hospital/Clinics______________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
The greatest gift this child has brought to our lives is_____________________________________
________________________________________________________________________________
________________________________________________________________________________
I am ordering:
Enclosed is a check in the amount of $____________________.
Or you may charge my Visa or Mastercard. My number is:
__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __ Expiration Date is ____ / ____.
Signature________________________________ Date__________________(January 2010)
First Name:_______________________ Last Name:___________________________________
Marital Status:(___) Married (___) Single (___) Separated (___) Divorced (___) Domestic Partners
(___) Widow/Widower (___) Remarried (___) Engaged....
Spouse's Name:____________________
Address:_____________________________________City:_______________________________________
State/Province:_______ Zip/Postal Code:___________County:__________Country:_____________
Home Phone_____-_____-_____ Work_____-_____-_____ Extension________
Email:______________________________ Website:____________________________________
(___) Adopted (___) Grandparent or relative (___) Multiple birth (___) Twin (___) Triplet
(___) Quadruplet Other:________________________________________________________
Primary Diagnosis (Be Specific!)________________________________________________
______________________________________________________________________________________________
Secondary conditions_________________________________________________________
__________________________________________________________________________________________
Did your child see a Geneticist? (___)Yes (___)No ...A Genetic Counselor? (___)Yes (___)No
Karyotype (chromosome results)____________________________________________________
______________________________________________________________________________
When was disability/disorder diagnosed? (___) Before birth (___) At birth, At age __________.
Apgar (score at birth) ____/____ Birth weight________ Seizures (___) Yes (___) No
Date of 1st known seizure__________Length of pregnancy(40 weeks is normal)_________weeks.
Type of seizures_________________________________________________________________
Medications taken presently___________________________________________________
Medications taken in the past__________________________________________________
Did your child have a bad reaction to a vaccine? (___) Yes (___) No
Explain vaccine reaction:
(___) High pitched scream (___) Seizure (___) Couldn't wake up (___)High Fever
Other reactions:__________________________________________________
Cause of Disability:________________________________________________________________
Cognitive Functioning Level:
(___) At developmental age level (___) Unknown
(___) Gifted (IQ Score=___) (___) Developmentally Delayed (___) Mild (___) Moderate (___) Severe, Functions at age level (_______)
(___)Scoots (___)Rolls
(___)Wheelchair -manual (___)Wheelchair - powerchair (___)No mobility
(___) kicks
(___) grabs toys
(___) Can Cath self (___) In Training
(___) Will always need diapers
(___) Says some words (___) Speaking Device (___) Does Not Communicate (___) Sign Language
(___) Coos (___) Smiles (___) Eye Contact (___) Laughs (___) Communicates with eyes
(___) Breastfed now. Breastfed for____months
(___) No help needed
(___) Some help needed
(___) Fed by others (___)Feeding tube (___) Button (___)NG (___)Broviac Line
(___) Wears Hearing Aides
Range of Hearing (_____) Right ear(______) Left ear
(___) Self-Abusive (___) Impulsive (___) Aggressive (___) Defiant (___) Eye Contact
Apnea monitor(___) now (___) in past; Colostomy (___) now (___) in past; Heart monitor (___) now (___) in past; Oxygen (___) now (___) in past; Shunt (___) now (___) in past; Suctioned (___) now (___) in past; Tracheotomy (___) now (___) in past; Ventilator
(___) now (___) in past;
Other:_______________________________________________________________________
_____________________________________________________________________________
Occupation_____________________Other parent's Occupation:______________________
Was either parent ever exposed to dangerous chemicals? (___)Yes (___) No
Please explain:________________________________________________________
Was either parent ever in the military? (___) Yes (___) No
Did either parent serve in a war? (___) Yes (___) No
(___) Vietnam
(___) Gulf War
(___) African-American Other:______________________________________________
____________________________________By: (___) Mother (___) Father (___) Sibling
Pediatric Neurologist___________________________
Cardiologist________________________
Heart Surgeon_____________________Orthopedic Surgeon_______________________________
Neurosurgeon_______________________
Pediatrician___________________________________
Geneticist ________________________Genetic Counselor________________________________
Craniofacial Surgeon_________________Pulmonary Specialist____________________________
Psychiatrist________________________Psychologist____________________________________
Attorney/Lawyer_____________________________________________________________________
Other___________________________________________________________________________________
I had a bad experience with the following doctor (s) (please explain and give name(s)):
_________________________________________________________________________________________
Do you feel you were informed and involved in the decisions made regarding the treatment of your child?__________________________________________________________________________
The biggest challenge with having a child with a disability is_______________________________
Please check the correct boxes and sign and date at bottom:
(___) Enclosed is $15.00
(____) I cannot afford the fee.
2. (___) I need _____more survey forms to fill out for my other child/children who have a disorder.
3. (___) If possible, I would like to be sent the names of parents with a child with the same or similar condition as my child.
(____)Enclosed is $10.00
(____)I cannot afford the fee, but want matches.
4. (___) You may let another parent whose child has a similar disorder call me to talk.
5. (___) I would like information about any support group for my child's disorder.
6. (___) You may release my name to people interested in contacting families about research involving my child's condition.
7. (___) Please do not release the above information to anyone!
8. (___) You may print my responses in the newsletter and print my name & address.
Print Phone:(___)Yes(___)No Print Email:(___)Yes(___)No
9. (___) You may print my responses in the newsletter using only initials and city and state.
10. (___) You may print my responses with only the diagnosis after it to protect my identity.
11. (___) I have enclosed a letter and you may print it in the newsletter with my name & address.
Print Phone:(___) Yes(___) No You may print my Email:(___)Yes(___)No
12. (___) I have enclosed a letter and you may print it in the newsletter with only initials and city and state.
13. (___) Enclosed is a picture of my child. (___)
You may print it in the newsletter.
(___) Newsletters ($15) (___)I can't afford to donate at this time.
(___) List of Parent Matches ($10) (___)I can't afford to donate at this time.
(___) Hyperbaric Oxygen Therapy (HBO) Packet ($25 Outside U.S. $35)
(___) The Oxygen Revolution book by Dr. Paul Harch ($25 outside U.S. $30)
(___) Donation to MUMS (Thanks!! :>}). (___)
Total Amount to be billed to credit card $________.