New Patient Intake Form

The following comprehensive form will require you to share your child's medical and developmental history to help us prepare for your child's first visit. You will be required to upload your photo ID and a prescription from your child's physician.
New Patient Intake Form
Today's Date

MonthDayYear
Child's Name

First NameMiddle NameLast Name
Birth date

MonthDayYear
Age
Years Months
Sex
Adopted?

YesNo
Parent/Guardian 1 completing this questionnaire:

First NameLast Name
Parent/Guardian 2 completing this questionnaire:

First NameLast Name
How did you hear about POTS
Who can we thank for referring you to POTS?
What brings you to POTS today?
What do you hope to gain from this evaluation?
What are your goals and aspirations for your child?
Has your family experienced any recent crisis or stress that you feel is important to your child’s development at this time?
Did either parent or any relative experience the same difficulties as your child? Please Explain:

Family
Parent #1 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Occupation
Email
example@example.com
Parent #2 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number

Area CodePhone Number
Occupation
Email
example@example.com

Names of siblings:

	Name	Age	Gender	School
Sibling
Sibling
Sibling
Sibling
Sibling
Sibling

Pediatrician
Child's Pediatrician

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Website
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long has your child been under this physician’s care?
Has your child been diagnosed as having any medical or educational condition? Please explain:
Who made the diagnosis and when was it made?
I give POTS permission to contact my child's Pediatrician/Specialist

	Check all that Apply
Fussy, irritable
Good, non-demanding
Quiet
Passive
Active
Liked being held
Resisted being held
Floppy
Tensed muscles when being held
Slept well
Irregular sleep patterns
Overly active, never still unless sleeping

Daily Schedule
My child is in school/day care from the hours of : to
Which days?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please describe your child’s morning routine (typical school day).
What factors most interfere with a smooth morning?
Provide an overview of your child’s usual after-school routine.
What are the biggest deterrents to a smooth evening?
How does your child choose to spend his/her free time at home?
Describe your child’s play. Does your child play appropriately with toys? What are his/her favorite play activities and themes?
How long does it take your child to fall asleep once put to bed? Please describe your child’s bedtime routine. What tends to relax or over-stimulate him/her at night? Does your child need someone nearby to fall asleep?
How does your child cope with weekends (e.g., more physically active, stays in front of the TV, play date with friends, type of demeanor compared to week days)?
What is his/her mood like when he/she returns to school after the weekend?

Behavior and Social Skills
Who is primarily responsible for discipline and rule setting at home?
What methods are most effective? How does your child respond to discipline?
How often does your child tantrum? Please describe.
Have you observed any head banging or self-destructive behavior?

YesNo
How does your child respond to authority figures outside of the home?
How does your child respond to structure and routine? Please elaborate:
Does your child have a “best friend”? Yes No
Older or younger? Older Younger Same age
Is your child attuned to social cues? Is he/she socially appropriate (at school, home, play date, party)?
How does your child do with one-on-one play dates? Does he/she request them?
Are you concerned with your child’s ability to function at birthday parties, other group or crowded situations? (e.g. guests at home, visiting friends or relatives, youth group, synagogue, church, mall, movie theater, etc.)

	Most	Some	All
Feeds self

Speech and Language History
Please describe your concerns:
When were you first concerned?
What strategies have you employed to help remediate the problem?
Present oral motor/communicative behavior?
If your chid communicates differently at home, daycare or school? Please explain:

Family history of communication or speech problems:

	Family Member
Speech/Oral Motor Problems
Stuttering (or cluttering)
Pacifier use
Thumb sucking
Learning problems
Cleft/lip palate
Neurological problems

At what age did your child begin to:

	Years	Months
Babble
Say first word
Combine words

What were your child's first words:
What were your child's first phrases or sentences:

Does child have difficulty with:

	Yes/No	Comments
Pronouncing sounds/words
Forming sentences
Following directions
Remembering
Stuttering
Vocabulary
Voice quality
Being understood by others

How much do you understand of your child’s speech?
How much do others not familiar with your child?
Explain:
How does speech, language, and oral motor deficits impact on your child’s ability to participate in school, at home and in the community?

Feeding History
Did your child have sucking difficulties at birth?

YesNo
Was/is your child breastfed or bottle fed?

BreastfedBottle fed

During feeding, did/does your child have difficulty with:

	Yes/No	Comments
Sucking
Food Tastes
Chewing
Food Textures
Swallowing
Food Temp.
Spitting out
Vomiting
Cup Drinking
Gagging
Drooling
Handling Utensils
Coughing
Choking

Has your child had a swallow study or video-fluoroscopy? If yes, when and where?

When did your child?

	Years	Months	Comments
Transition from bottle to cup drinking
Transition from baby to table food
Feed self independently

What does your child currently drink from?

Sippy cupStrawOpen cup
Any difficulties with positioning or sitting at the table to support feeding?
How long does it take your child to eat a typical meal?
Does your child have food allergies? If yes, to what?

Prescription and Photo ID
Please upload a photo of your child

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Please upload your child's prescription

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Please upload your photo ID

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Date

MonthDayYear
Signature*

Clear
By signing your name above, you agree that your digital signature, can be used as your actual signature.
Should be Empty:

	Name	Date(s) seen	Phone number	Findings
Pediatric Neurologist
Developmental Pediatrician
Learning Specialist
Psychologist
Psychiatrist
Speech Pathologist
Audiologist
Physical Therapist
Occupational Therapist
Developmental Optometrist
Ophthalmologist
Nutritionist
ENT
Child Study Team
Other

	Currently unable	Delayed	Met on time	I don't know
Rolled by 7 mo
Crawled by 10 mo
Reached by 6 mo
Walked by age 13-16
Finger fed by 16
Drank from open a cup by 18 mo
Ate with spoon by 2 yr
Draw a circle by 3 yr
Dressed self by 3 yr
Clothing fasteners by 4 yr (tie bow by age 6)
Toilet trained by 4 yr
Cut with scissors by 4 yr
Use knife for cutting by 5 yr

	Years	Months
Raised head
Pulled to standing
Crawled on hands and knees
Stood alone
Sat alone
Walked
Babbled
Spoke in sentences
Said first word

	Advanced	Normal	Slow
Gross motor: (running, jumping, ball play)
Fine motor: (beading, lacing, cutting with scissors)
Handwriting/coloring skills:
Speech
Language
Hearing

	Remove	Put on
Undershirt
Socks
Shirt
Shoelaces
Underpants
Shoes
Pants
Buttons
Snaps
Velcro closures
Zippers
Jacket

New Patient Intake Form

Family

Pediatrician

Medical History

Developmental History

Daily Schedule

Behavior and Social Skills

Occupational History

Level of Concern

Self-care Skills

Bathing

Toilet Training

Speech and Language History

Feeding History

Educational History

Prescription and Photo ID

	A lot	Some	None
Face
Hair
Dry off

	Academic GOOD	Academic Average	Academic Poor
Preschool
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4 +

	Student Skills GOOD	Student Skills AVERAGE	Student Skills POOR
Preschool
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4 +