New Pediatric Patient Registration Form

New Patient Registration

Please fill in the form below.
Patient Information

Please answer each question to the best of your knowledge.
Patient Name*

First Name Middle Name Last Name
Address:*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Date of Birth*

Month Day Year
Phone Number*

Area Code Phone Number
Referred By:

First Name Last Name
Parent/Guardian Name (# 1)

First Name Last Name
Parent/Guardian Name (#2)

First Name Last Name
Parent Email Address
Patient Sex
What different languages is your child exposed to?*
What languages do they speak and understand?
What is your major concern and/or the primary reason for your visit?*
Medical History

Please complete each question to the best of your knowledge.
Pediatrician's Name

First Name Last Name
What was the mother's length of pregnancy with the patient?

37-42 weeks30-36 weeks25-29 weeks25 < weeks
Was the mother's labor:

SpontaneousInducedVaginalC-Section
Patient's birth weight (pounds)
Has the patient experienced any of the following medical complications?

AIDS/HIVAsthmaAutismAllergy/Sinus ProblemsADHD/ ADDBehavioral DisorderBlood DisorderCancerChicken PoxDevelopmental DelayDiabetesEndocrine System DisorderGenetic DisordersEar InfectionsGastrointestinal ProblemsHead InjuryHeadachesHeart ProblemsHearing LossLearning DisabilityInfluenzaMeningitisMalariaPhysical ImpairmentMeaslesScarlet FeverNeurologic DisorderShort Attention SpanVision lossStrokeUTITonsilitisSeizuresNone of these
Approximate Date of Client Diagnosis? (if applicable)
MM/DD/YYYY
Did any of the following complications apply AFTER birth?

AIDS/ HIVBorn With Low OxygenBlue colorBreech BirthCMVHeart/CardiovascularInfection of baby or motherFailed Newborn HearingJaundiceLow birth weight (< 5.5 pounds)Low APGAR SCORENuchal Cord (Umbilical cord around neck)Respiratory DifficultiesProlonged Stay at NICUShaken BabyBreastfeeding difficultiesNone of these
When did your Child achieve the following milestones?
Please list your child's major medical history, surgeries, and/or symptoms. *
Please list your child's medical diagnoses.
Please check which specialist your child has seen:*

Child PsychiatristDevelopmental PediatricianEar Nose Throat (ENT)Gastroenterologist (GI)GeneticistNeurologistOphthalmologist/OptometristNone listedorthopedistpsychiatrist
Has their hearing been checked?

Passed newborn hearing screening.Passed screening within the past 12 months.Failed hearing test
Does your child currently or previously have frequent ear infections?

YesNo
Is the patient currently taking any medication?*

YesNo
If yes, please list medications here:
Please list any allergies:*
Does your child currently or previously receive therapy services?

YesNo
If yes, please list the clinic name, length of time, and specific services received.
What are your child's strengths?
What does your child love to do?
What does your child avoid doing?
Speech- Language History
What is your primary concern regarding the patient's speech/language?

Early Language DelayArticulationLanguageFluency/StutteringReading/LiteracyApraxiaAACLow Tone/DysarthriaFeedingAutism (even if not diagnosed yet)Social languageNone of the above
When did the patient say his/her first word?

12 months24 monthsGreater than 24 monthsMy child is not speaking at this time
Approximately how many total words does the patient use?
How does your child request for things?
How does your child protest or tell you he/she doesn’t want something?
How does your child get your attention?
How well do you understand your child?

Less than 25%Between 25-50%Between 50-75%More than 75%
Does your child suck their thumb or finger?

YesNoPreviously
If Previously, when did they stop?
Does your child use a pacifier?

YesNoPreviously
If previously, when did they stop?
Does your child have any of these symptoms?

Mouth Breather (mouth is open most the time)Sleeps with mouth openStuffy nose oftenHoarse VoiceCavitiesNeeds braces or will need bracesOpen BiteAdenoids/Tonsils RemovedSnoresWakes up multiple times during the nightPicky EaterTongue and/or lip tie
Occupational Therapy
What are your main concerns for your occupational therapist?
What is your main goal for your child in receiving occupational therapy?
How many siblings does your child live with?
Daily Activities

Does your child...
Have difficulty with bathing?

YesNo
Have difficulty with dressing?

YesNo
Have difficulty with dressing?

YesNo
Have difficulty tying their shoes?

YesNo
Avoid certain textures on clothing? (Shirt tags, wool, silk, cotton, etc.)

YesNo
Toilet trained?

YesNo
Is your child a "picky eater"?

YesNo
Eat less than 10 foods?

YesNo
Eat brand specific foods? (Only Aunt Jemima pancakes, only Tyson chicken fingers, etc.)

YesNo
Was breastfed?

YesNo
Prefer hard, crunchy foods?

YesNo
Prefer soft foods?

YesNo
Have a strong preference for certain flavored foods? (Spicy, sweet, salty)

YesNo
Prefer foods at suspiciously different temperatures than others?

YesNo
If yes, which?

Very very hotCold
Have trouble chewing?

YesNo
Have trouble swallowing?

YesNo
Have trouble using utensils? (Fork, spoon, knife)

YesNo
What do they prefer to drink out of?

Open CupCup with StrawBottle with Nipple
Resist having their nails clipped?

YesNo
Resist having their hair touched?

YesNo
Resist having their feet touched?

YesNo
Resist having their hair cut or brushed?

YesNo
Resist having their teeth brushed?

YesNo
Mobility

Does your child...
Avoid walking or running?

YesNo
Currently or previously avoid crawling?

YesNo
Walk on their toes?

YesNo
Have trouble sitting still?

YesNo
Appear more clumsy than peers? (Running into others, walls, falling often)

YesNo
Struggle with running, riding a bicycle, or climbing?

YesNo
Sleep

Does your child...
How many hours does your child sleep at night?
Have a hard time falling asleep?

YesNo
Have a hard time staying asleep?

YesNo
Have a hard time waking up in the morning?

YesNo
School

Does your child...
Attend school or day care?

YesNo
What school does your child attend?
What grade is your child in?
Does your child have an IEP or 504 Plan?

YesNo
Have difficulty completing schoolwork on time?

YesNo
Is your child easily distracted?

YesNo
How long can your child focus on a non-electronic task?
Have difficulty with handwriting?

YesNo
Have trouble sitting still in class?

YesNo
Have difficulty reading textbooks?

YesNo
Have difficulty reading from the board?

YesNo
Play

Does your child...
Play well with others?

YesNo
Have difficulty or lack interest in age-appropriate toys?

YesNo
Play alone when playing with others?

YesNo
Play too rough with others?

YesNo
Is your child controlling when playing with others? (Always makes the rules, must win, etc.)

YesNo
Social

Does your child...
Have trouble interacting with peers?

YesNo
Hesitate to socialize or withdraw from play or communicating with peers?

YesNo
Have difficulty understanding others' feelings or emotions?

YesNo
Tend to cry easily when under stress when compared to others?

YesNo
Express concern or worry often?

YesNo
Often get sad, easily?

YesNo
Engage in repetitive and self-harming behavior? (Skin pulling, hair pulling, hitting)

YesNo
Express concerns about not being as good as their peers?

YesNo
How long does your child's tantrums last?
How many tantrums does your child have a month?
Engage in aggressive behavior towards peers? (Hitting, biting, pushing, etc.)

YesNo
Physical Therapy
What are your main concerns in the area of Physical Therapy?

strengthbalancenot keeping up with peersSitting PostureStanding Postureendurancecoordinationball skillswalking/running
Was your child delayed in achieving any developmental milestones?
Should be Empty:

New Patient Registration

Patient Information

Medical History

Speech- Language History

Occupational Therapy

Daily Activities

Mobility

Sleep

School

Play

Social

Physical Therapy