Referral Date
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Today M-D-Y
Are you a member of:
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Mount Sinai Health System
NYU Langone
RWJ Barnabas
Tulane
AHRC
Boston Children's Hospital
YAI
Other
Mount Sinai Health System
NYU Langone
RWJ Barnabas
Tulane
AHRC
Boston Children's Hospital
YAI
Other
Mount Sinai Provider Name
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Fields LaVega-Talbot Marcuse Martinez Molofsky Raynes Wolf/McGoldrick Yoo Other
Devinsky
RWJ Barnabas Provider Name
Devinsky
Sofio Other
Wolf/McGoldrick
Boston Children's Hospital Provider Name
Wolf/McGoldrick Other
Provider Name and Contact Details
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Date the invitation was last sent to provider for verification
Today M-D-Y
Hospital Center
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MSH MSW DDC PACC Hartsdale CFD Other
Where is this patient seen?
EPIC MRN
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Gender
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Female
Male
Based on your response, this individual is not seen within the Mount Sinai Health System and therefore cannot be found by our team on EPIC.
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Date of birth
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Today M-D-Y
Age at time of referral (years)
View equation Asian African American/Black Caucasian/White Mixed Native American/Alaskan Native (First Peoples) Native Hawaiian/Pacific Islander Other Unknown
Hispanic Not Hispanic Unknown
Has this patient been diagnosed with Autism Spectrum Disorder?
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Yes
No
Age of onset for Autism Spectrum Disorder?
In years and months
ASD age of diagnosis (years)
ASD age of onset (months)
ASD age of diagnosis (months)
Unknown
ASD age of diagnosis unknown
Unknown
Age of Autism Spectrum Disorder onset
Please specify the approximate developmental period ASD symptoms began, if known
Unknown
Birth
Infancy
Childhood
Adolescence
Adult (>21 years)
Unknown
Birth
Infancy
Childhood
Adolescence
Adult (>21 years)
Please specify the instrument(s) used to diagnose autism/ASD
ADOS
ADI
DSM-V
Unknown
Other
Please list other instrument(s) when applicable
Age of Autism Spectrum Disorder diagnosis
Please specify the approximate developmental period the ASD diagnosis was made, if known
Unknown
Birth
Infancy
Childhood
Adolescence
Adult (>21 years)
Unknown
Birth
Infancy
Childhood
Adolescence
Adult (>21 years)
ASD Age of Onset (months)
View equation ASD Age of Diagnosis (months)
View equation Has this patient been diagnosed with epilepsy/a seizure disorder?
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Yes
No
Abnormal EEG only
Please indicate if any of the following additional diagnoses/EEG patterns are present
Landau-Kleffner Syndrome (LKS)
Continuous Spikes and Waves During Sleep (CSWS)
Electrical Status Epilepticus During Slow Sleep (ESES)
Beta activity
Photosensitivity/photoparoxysmal activity
Other
Landau-Kleffner Syndrome (LKS)
Continuous Spikes and Waves During Sleep (CSWS)
Electrical Status Epilepticus During Slow Sleep (ESES)
Beta activity
Photosensitivity/photoparoxysmal activity
Other
Please specify the other abnormal EEG pattern observed in this patient
In years and months
Age of onset for epilepsy
In years and months
Epilepsy age of onset (years)
Epilepsy age of diagnosis (years)
Epilepsy age of onset (months)
Epilepsy age of diagnosis (months)
Age of epilepsy onset is unknown
Unknown
Age of Epilepsy diagnosis is unknown
Unknown
Please specify the approximate developmental period the first seizures occurred, if known
Unknown
Birth
Infancy
Childhood
Adolescence
Adult (>21 years)
Unknown
Birth
Infancy
Childhood
Adolescence
Adult (>21 years)
Age of epilepsy diagnosis
Please specify the approximate developmental period the epilepsy diagnosis was made, if known
Unknown
Birth
Infancy
Childhood
Adolescence
Adult (>21 years)
Unknown
Birth
Infancy
Childhood
Adolescence
Adult (>21 years)
Epi Age of Onset (months)
View equation Epi Age of Diagnosis (months)
View equation Epilepsy type(s)
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Idiopathic generalized epilepsy
Non-acquired focal epilepsy
Lesional focal epilepsy
Epileptic Encephalopathy
Unknown
Other
Idiopathic generalized epilepsy
Non-acquired focal epilepsy
Lesional focal epilepsy
Epileptic Encephalopathy
Unknown
Other
Childhood Epilepsy with Centrotemporal Spikes
Atypical Childhood Epilepsy with Centrotemporal Spikes
Benign Occipital Epilepsy (Panayiotopoulos)
Benign Occipital Epilepsy (Gastaut)
Idiopathic photosensitive occipital lobe epilepsy
Frontal Non-lesional epilepsy with clinical and/or EEG evidence of a frontal localization
Frontotemporal Non-lesional epilepsy with clinical and/or EEG evidence of a frontotemporal localization
Temporal Non-lesional epilepsy with clinical and/or EEG evidence of a temporal localization that does not meet the criteria for Childhood Epilepsy with Centrotemporal Spikes.
Mesial temporal lobe epilepsy secondary to hippocampal sclerosis can be included here.
Occipital Non-lesional epilepsy with clinical and/or EEG evidence of an occipital localization that does not meet the criteria for any of the benign occipital epilepsy syndromes
Temporoccipital Non-lesional epilepsy with clinical and/or EEG evidence of a temporoccipital localization
Parietal Non-lesional epilepsy with clinical and/or EEG evidence of a parietal localization
Multifocal Non-lesional epilepsy with clinical and/or EEG evidence of more than one localization.
Unspecified Non-lesional epilepsy with clinical and/or EEG evidence of focal onset but the specific localization is undetermined
Childhood Epilepsy with Centrotemporal Spikes
Atypical Childhood Epilepsy with Centrotemporal Spikes
Benign Occipital Epilepsy (Panayiotopoulos)
Benign Occipital Epilepsy (Gastaut)
Idiopathic photosensitive occipital lobe epilepsy
Frontal Non-lesional epilepsy with clinical and/or EEG evidence of a frontal localization
Frontotemporal Non-lesional epilepsy with clinical and/or EEG evidence of a frontotemporal localization
Temporal Non-lesional epilepsy with clinical and/or EEG evidence of a temporal localization that does not meet the criteria for Childhood Epilepsy with Centrotemporal Spikes.
Mesial temporal lobe epilepsy secondary to hippocampal sclerosis can be included here.
Occipital Non-lesional epilepsy with clinical and/or EEG evidence of an occipital localization that does not meet the criteria for any of the benign occipital epilepsy syndromes
Temporoccipital Non-lesional epilepsy with clinical and/or EEG evidence of a temporoccipital localization
Parietal Non-lesional epilepsy with clinical and/or EEG evidence of a parietal localization
Multifocal Non-lesional epilepsy with clinical and/or EEG evidence of more than one localization.
Unspecified Non-lesional epilepsy with clinical and/or EEG evidence of focal onset but the specific localization is undetermined
Childhood Absence Epilepsy
Epilepsy with Myoclonic Absences
Childhood Absence Epilepsy/ Juvenile Absence Epilepsy Overlap
Juvenile Absence Epilepsy
Juvenile Myoclonic Epilepsy
Epilepsy with Generalized Tonic-Clonic Seizures Alone
Late Onset GGE
Early Onset Absence Epilepsy
Epilepsy with Eyelid Myoclonia
Generalized Unspecified
Other
Childhood Absence Epilepsy
Epilepsy with Myoclonic Absences
Childhood Absence Epilepsy/ Juvenile Absence Epilepsy Overlap
Juvenile Absence Epilepsy
Juvenile Myoclonic Epilepsy
Epilepsy with Generalized Tonic-Clonic Seizures Alone
Late Onset GGE
Early Onset Absence Epilepsy
Epilepsy with Eyelid Myoclonia
Generalized Unspecified
Other
Neonatal onset
Early onset epileptic encephalopathy (< 3 months)
Infantile onset epileptic encephalopathy (not otherwise specified)
Epilepsy of infancy with migrating focal seizures
West syndrome/infantile spasms
Late-onset epileptic spasms
Lennox-Gastaut syndrome
Epilepsy with myoclonic atonic seizures
Dravet syndrome
Landau-Kleffner syndrome (LKS)
Epileptic encephalopathy with continuous spike-and-wave during sleep (CSWS)
Febrile Infection Related Epilepsy Syndrome (FIRES)
Hemiconvulsion-Hemiplegia-Epilepsy
Nonsyndromic epileptic encephalopathy with focal seizures
Nonsyndromic epileptic encephalopathy with generalized seizures
Nonsyndromic epileptic encephalopathy with mixed or unclassified seizures
Neonatal onset
Early onset epileptic encephalopathy (< 3 months)
Infantile onset epileptic encephalopathy (not otherwise specified)
Epilepsy of infancy with migrating focal seizures
West syndrome/infantile spasms
Late-onset epileptic spasms
Lennox-Gastaut syndrome
Epilepsy with myoclonic atonic seizures
Dravet syndrome
Landau-Kleffner syndrome (LKS)
Epileptic encephalopathy with continuous spike-and-wave during sleep (CSWS)
Febrile Infection Related Epilepsy Syndrome (FIRES)
Hemiconvulsion-Hemiplegia-Epilepsy
Nonsyndromic epileptic encephalopathy with focal seizures
Nonsyndromic epileptic encephalopathy with generalized seizures
Nonsyndromic epileptic encephalopathy with mixed or unclassified seizures
Other epilepsy type not listed above
Does ______ ______ have intellectual disability?
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No
Yes
Unknown
Level of impairment
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Mild (F70; IQ 50-70)
Moderate (F71; IQ 35-40 to 50-55)
Severe (F72; IQ 20-25 to 35-40)
Profound (F73; IQ below 20 or 25)
Other Intellectual disabilities (F78)
Unspecified intellectual disabilities (F79)
Unknown
Mild (F70; IQ 50-70)
Moderate (F71; IQ 35-40 to 50-55)
Severe (F72; IQ 20-25 to 35-40)
Profound (F73; IQ below 20 or 25)
Other Intellectual disabilities (F78)
Unspecified intellectual disabilities (F79)
Unknown
Is this patient's diagnosis indicative of a syndrome?
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Yes
No
Unknown
Please specify syndrome (if known)
Please confirm if any of the following additional syndromes or diagnoses are present
LKS/ESES
Rett/Rett-like
Tuberous Sclerosis
Other
LKS/ESES
Rett/Rett-like
Tuberous Sclerosis
Other
Other Diagnoses **OLD DEPRECATED**
Optional
Other diagnoses/syndromes
Optional
Has this individual had previous genetic testing?
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Yes
No
Has this individual failed two or more anti-epileptic drugs?
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Yes
No
Has this individual undergone resective surgery?
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Yes
No
Unknown
(OPTIONAL) Please describe dates performed and resected regions of any previous surgeries
Is this individual a candidate for brain surgery?
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Yes
No
(OPTIONAL) Please list the procedures for which this individual is a candidate
Are you referring this individual to the genetic screening [research]?
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Yes
No
Certification Statement
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I certify that all information provided as part of this referral is true and correct to the best of my knowledge.
I certify that this referral cannot be verified, as this patient is no longer seen at the referring institution, and available notes/EMRs are insufficient to verify the diagnoses.
I certify that all information provided as part of this referral is true and correct to the best of my knowledge.
I certify that this referral cannot be verified, as this patient is no longer seen at the referring institution, and available notes/EMRs are insufficient to verify the diagnoses.
Referral contains data that cannot be cleaned/should be verified with provider
Yes
Yes
No
Today M-D-Y
This record has passed the Duplicate Check
Yes
No
Move this referral to the NeuroDevelopmental Disorders Data Collection Project. Click 'Yes' to generate a new Family record for data collection (Note: this action cannot be undone except by manually deleting the corresponding record in the NeuroDevelopmental Disorders Data Collection Project).
Yes
No
ID of the corresponding family in the NeuroDevelopmental Disorders Data Collection Project.
Submit
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