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New Patient Intake








Identifying and Family Information

Date:

Patient Information

Child’s Full Name:

Child’s Date of Birth:

Child’s Gender:

Medical Diagnosis:

Medications:

Child’s Pediatrician:

Pediatrician’s Practice Name:

Child’s Teacher:

Child’s School:

How did you hear about us:
WebsiteFacebookTwitterGoogle+Doctor (please specify name below)Friend/FamilyOther (please specify below)

Contact Information

Parents Full Name:

Address:

City:

State:

Zip Code:

Day Time Phone:

Cell Phone:

Email Address:

Emergency Contact (if parent/guardian can’t be reached)

Emergency Contact Name:

Emergency Contact Phone:

Relation to Patient:


Medical History

Was there anything unusual about the pregnancy or birth: YesNo

If yes, please describe:

Has your child ever experience any of the following or received any medical diagnoses:

If Ear Infections, How Often:

If Ear Tubes, When:

If Head injury, When:

Does your child have a hearing loss:
YesNo

If yes, does your child wear hearing aids/cochlear implants:
YesNo

Does your child have a vision loss or vision problems:
YesNo

If yes, does your child wear corrective lenses:
YesNo

Other Serious Injuries/Surgeries:

Are your child’s vaccinations up to date:YesNo


Developmental History

Please fill-in the approximate age which your child achieved the following developmental milestones

Babbled:

Said First Word:

Put Two Words Together:

Spoke in Short Sentence:

Toilet Trained:

Sat Alone:

Crawled:

Walked:

Does your child…
Choke on food and/or liquids: YesNo
Currently put toys/objects in his or her mouth: YesNo
Brush his or her teeth and/or allow brushing: YesNo


Background Information

Does your child have any vision/hearing/medical problem/disability or diagnosis at this stage:

Has your child ever undergone a speech evaluation/screening: YesNo

If yes, where and when:

Has your child received speech therapy in the past: YesNo

If yes, where and when:

What was he/she working on:

Has your child ever undergone an occupational therapy evaluation/screening: YesNo

If yes, where and when:

Has your child received occupational therapy in the past: YesNo

If yes, where and when:

What was he/she working on during the occupational therapy:

Has your child received any other evaluation or therapy (ie. Physical therapy, counseling, vision, developmental therapy, etc.): YesNo

If yes, please describe:


Communication Information

Please share your concerns about your child’s communication abilities:

Is your child aware of, or frustrated by, their speech/language difficulties:
YesNo

Please explain:

What do you see as your child’s most difficult communication challenge(s) at home:

Is there a language other than English spoken in the home: YesNo

If yes, which language:

Does the child speak the language: YesNo

Does the child understand the language: YesNo

Which language does the child prefer to speak:


Behavioral Characteristics

Please check all traits which best characterize your child’s current behavioral characteristics:
CooperativeEasily distractedDestructive/aggressivePlays alone for reasonable length of timePoor eye contactWithdrawnInappropriate behaviorAttentive/InattentiveSeparation difficultiesEasily frustratedImpulsiveRepetitive behaviorSlow WorkerRestlessHyperactive
Difficulty with:
Following DirectionsRemembering InformationInitiating TasksFinishing TasksTransitioningRegulating behavior
Please describe:


School History

(If N/A, please continue to next section)

What grade is your child in:

Has he or she ever repeated a grade: If so, which:

Is your child in IEP: YesNo

Is your child having difficulty with any particular subjects: YesNo

If so, please describe:

What are your child’s strengths and/or best subjects:

What do you see as your child’s most difficult challenge at school:


Occupational Therapy Information

Please share your main concerns about your child’s sensory/motor/self-care/feeding abilities:



Please identify any strategies or interventions you have tried at home:

Strategy Length of Time Tried Outcome

Sensory Motor

Sensory Feeding/Oral Motor
Check all that apply, be sure to mention any specifics in the textarea below.
Does your child refuse new foods/texture?Does your child eat a very limited diet for age (10 or less foods?) If so, specify below what your child's typical diet looks likeDoes your child drool excessively (past the teething stage)?Does your child refuse to have his/her teeth brushed?Does your child refuse to touch food with his/her hands?Does your child cry or tantrums inconsolably if spills food or drink on self?Does your child always have something in his/her mouth, or is chewing on clothes, hands, fingers (past the teething stage)?Does your child refuse to drink from any cup except for his/her 1 favorite cup?
Sensory Feeding/Oral Motor Specifics:

 

Gross Motor
Check all that apply, be sure to mention any specifics in the textarea below.
Seems weaker than other his age, tires easilyDifficulty with hop, jump, skip, or run compared to others his ageClumsy, seems not to know how to move body, bumps into things, falls out of chairTendency to confuse right and leftReluctant to participate in playground activities and sports; fearful of movementSlumps or slouches when seated, leans on others when standingTakes movement or climbing risks that compromise personal safetyIs 'on the go'Becomes overly excitable during movement activityLikes to jump/hop/spin/throw self to the ground/bang into objects more than others
Gross Motor Specifics:

 

Fine Motor
Check all that apply, be sure to mention any specifics in the textarea below.
Poor desk posture; slumps, leans on armDifficulty managing fasteners (buttons/zippers/snaps/etc) needed for dressingUnable to tie shoes (if school age)Difficulty drawing, coloring, copying, cutting; avoidance of these activitiesDifficulty writing (if school age), head too close to work, other hand does not assistPoor pencil grasp; drops pencil frequently or holds on too tightLines drawn are tight/ wobbly/ too faint or too dark/ breaks pencil oftenLack of well established hand dominance after six years of ageUnable to write his name legibly (if school age)
Fine Motor Specifics:

 

Touch (tactile) Sensation
Check all that apply, be sure to mention any specifics in the textarea below.
Seems to withdraw from or react emotionally to touch, is bothered by tags/seams in socksAvoids getting 'messy' (ie. Finger paint, sand, glue, food stuffs)Shows distress during grooming (i.e. brushing of hair/teeth, nail clipping, hair cuts etc)Becomes irritated by shoes/socks or is sensitive to certain fabricsDislikes being cuddled or huggedWalks on toesPicky EaterTends to wear coat when not needed or won't take shoes offSeeks hugsHas trouble keeping hands to self, will poke or push others to the point of irritating themUnusual need for touching certain toys, surfaces, or texturesDecreased awareness of pain or temperature; high toleranceDoesn't seem to notice when someone touches arm/back, or when hands/face are messy
Touch Sensation Specifics:

 

Hearing
Check all that apply, be sure to mention any specifics in the textarea below.
Seems bothered by ordinary household sounds (vacuum cleaner, hair dryer, toilet etc)Holds hands over ears to protect ears from soundResponds negatively to unexpected or loud noises (i.e. cries or hides)Is distracted or has trouble completing tasks if there is a lot of noise or with background noise (i.e. radio, fan refrigerator, busy environment)Appears not to hear what is said (does not 'tune in') despite good hearingChild has difficulty making himself understoodAppears to have difficulty understanding youTends to repeat directions to self
Hearing Specifics:

 

Vision/Visual Perceptual
Check all that apply, be sure to mention any specifics in the textarea below.
Avoids or expresses discomfort with bright light; happy to be in the darkCovers eyes or squints to protect eyes from lightAvoids eye contact; fleeting eye contactLooks carefully or intensely at objects/people/; enjoys watching objects that spin, light upDoesn't notice when people enter the room; doesn't notice changes in detailsDifficulty finding an object by color, shape, in a group; difficulty doing puzzlesDifficulty paying attention if there is a lot to look atBothered by busy visual environments (cluttered room or store)Difficulty copying designs, numbers or letters from paper (near point) or board (far point)Letter reversals after first grade
Vision/Visual Perceptual Specifics:

 

Emotional/Behavioral
Check all that apply, be sure to mention any specifics in the textarea below.
Difficulty tolerating changes in routines, plans and expectations; does not accept changesEngages in rituals to complete personal routinesBecomes easily frustratedActs out behaviorally, difficulty getting along with othersSeems oblivious in an active environmentDisplays excessive emotional outbursts when unsuccessful at a taskMarked mood variations, outbursts or tantrumsUses inefficient ways of doing things (moves slowly, wastes time)Is impulsive, not waiting for full instructions or thinking before actingJumps from one activity to another so it interferes with playWithdraws from social situations or hides from interactionsRepetitive play, has difficulty coming up with ideas for new games/activities
Emotional/Behavioral Specifics:

Is there any additional information you would like the occupational therapist to know regarding your child: