Please carefully read and submit the following form for pediatric occupational and/or physical therapy. Child Intake Form Occupational/Physical Therapy Individualized Needs AssessmentFor Pediatric Occupational Therapy and/or Physical TherapyChild's Name* First Last Child's Date of Birth MM slash DD slash YYYY Name of Person Completing This Form* First Last Your relationship to the child:* Is your child adopted?* Yes No Foster child I am a relative/legal guardian Child's Birth HistoryChild was born:* Full term Premature If the child was born prematurely, how many weeks of gestation were they at birth? How was the child delivered?* Vaginal C-section Was your child in the NICU for any amount of time? If yes, for how long?*Please describe any medical or other complications during pregnancy, labor & delivery or shortly after birth.*If not applicable, type N/A.Developmental HistoryPlease indicate at what age your child did each of the following.*Rolled overSat aloneCrawledPulled to standStood aloneWalked aloneIf your child has not yet achieved the listed milestone, type N/A for not applicable.Please indicate at what age your child did each of the following.*BabbledSaid 1st wordDrank from cupUsed a spoonToilet-trainedDressed selfIf your child has not yet achieved the listed milestone, type N/A for not applicable.Explain any current physical limitations your child has.*Any additional comments on your child's development?*Medical HistoryList your child's current diagnosis or diagnoses.*Has your child had any prior hospitalizations? Answer Yes/No. If yes, please describe.*Has your child had previous surgeries or are they scheduled for any? Answer Yes/No. If yes, please describe.*Has your child had a previous psychological evaluation? Answer Yes/No. If yes, please describe.*Name of current physician.* Phone number of current physician.*List any medications your child is currently taking.*If none, type N/A for not applicable.List any special equipment your child uses, such as splints, braces, adaptive utensils or other.*If none, type N/A for not applicable.Do you have any feeding problems or nutritional concerns? Answer Yes or No. If yes, please describe.*Please check all that apply to your child.* Trach C-Line G-Tube Allergies Latex sensitivity Seizures Hearing aids Hearing difficulty Wears glasses Vision problems None of the above If your child has allergies, please detail what those are.Any other aspects of your child's health that his/her OT or PT should know about?*Caregiver ConcernsWhat are your main concerns with your child?*What are your child's strengths?*Indicate which of the following your child has received before & for how long. Type N/A for those that are not applicable.*Speech therapyOccupational therapyPhysical therapyABA therapyEducational InformationSchool/educational program child currently attends.* Current grade level.* Check any of the following services that your child receives in school.* Speech therapy. Occupational therapy. Physical therapy. Special education/IEP. Behavior intervention. Other special services. None of the above. Has your child's teacher expressed concern about your child's development in any of the following areas?* Motor skills Social abilities Self-help skills Learning abilities Other None of the above Check all that apply.Additional comments on your child's education?*Social/Emotional DevelopmentDoes your child interact well with others?* Yes No Does your child have trouble making friends?* Yes No Detail your child's fears and coping behaviors.*Does your child have trouble calming himself/herself when upset?* Yes No Any additional thoughts/comments on your child's social/emotional development?*BehaviorPlease check all the following that applies to your child.* Cries often Frequent temper tantrums Anxious Troubling following directions Trouble following routines Clumsy Weak muscles Picky eater Mouths objects Dislikes hair brushing Dislikes brushing teeth Avoids touch from others Dislikes playground equipment Seems to be always "on-the-go" Rocks self Sensitive to light Sensitive to sound Poor attention span Other None of the above If you answered "other" to the previous question, please give us more details.Parent SignatureConsent* I agree this information is true and accurate to the best of my knowledge.Date this form was completed:* MM slash DD slash YYYY Your phone number.*Your email address.* Δ
