Language
English (US)
Spanish (Latin America)
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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Date of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
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31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
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1984
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1936
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
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
Male
Female
N/A
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 weeks
30-36 weeks
25-29 weeks
25 < weeks
Was the mother's labor:
Spontaneous
Induced
Vaginal
C-Section
Patient's birth weight (pounds)
Has the patient experienced any of the following medical complications?
AIDS/HIV
Asthma
Autism
Allergy/Sinus Problems
ADHD/ ADD
Behavioral Disorder
Blood Disorder
Cancer
Chicken Pox
Developmental Delay
Diabetes
Endocrine System Disorder
Genetic Disorders
Ear Infections
Gastrointestinal Problems
Head Injury
Headaches
Heart Problems
Hearing Loss
Learning Disability
Influenza
Meningitis
Malaria
Physical Impairment
Measles
Scarlet Fever
Neurologic Disorder
Short Attention Span
Vision loss
Stroke
UTI
Tonsilitis
Seizures
None of these
Approximate Date of Client Diagnosis? (if applicable)
MM/DD/YYYY
Did any of the following complications apply AFTER birth?
AIDS/ HIV
Born With Low Oxygen
Blue color
Breech Birth
CMV
Heart/Cardiovascular
Infection of baby or mother
Failed Newborn Hearing
Jaundice
Low birth weight (< 5.5 pounds)
Low APGAR SCORE
Nuchal Cord (Umbilical cord around neck)
Respiratory Difficulties
Prolonged Stay at NICU
Shaken Baby
Breastfeeding difficulties
None 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 Psychiatrist
Developmental Pediatrician
Ear Nose Throat (ENT)
Gastroenterologist (GI)
Geneticist
Neurologist
Ophthalmologist/Optometrist
None listed
orthopedist
psychiatrist
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?
Yes
No
Is the patient currently taking any medication?
*
Yes
No
If yes, please list medications here:
Please list any allergies:
*
Does your child currently or previously receive therapy services?
Yes
No
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 Delay
Articulation
Language
Fluency/Stuttering
Reading/Literacy
Apraxia
AAC
Low Tone/Dysarthria
Feeding
Autism (even if not diagnosed yet)
Social language
None of the above
When did the patient say his/her first word?
12 months
24 months
Greater than 24 months
My 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?
Yes
No
Previously
If Previously, when did they stop?
Does your child use a pacifier?
Yes
No
Previously
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 open
Stuffy nose often
Hoarse Voice
Cavities
Needs braces or will need braces
Open Bite
Adenoids/Tonsils Removed
Snores
Wakes up multiple times during the night
Picky Eater
Tongue 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?
Yes
No
Have difficulty with dressing?
Yes
No
Have difficulty with dressing?
Yes
No
Have difficulty tying their shoes?
Yes
No
Avoid certain textures on clothing? (Shirt tags, wool, silk, cotton, etc.)
Yes
No
Toilet trained?
Yes
No
Is your child a "picky eater"?
Yes
No
Eat less than 10 foods?
Yes
No
Eat brand specific foods? (Only Aunt Jemima pancakes, only Tyson chicken fingers, etc.)
Yes
No
Was breastfed?
Yes
No
Prefer hard, crunchy foods?
Yes
No
Prefer soft foods?
Yes
No
Have a strong preference for certain flavored foods? (Spicy, sweet, salty)
Yes
No
Prefer foods at suspiciously different temperatures than others?
Yes
No
If yes, which?
Very very hot
Cold
Have trouble chewing?
Yes
No
Have trouble swallowing?
Yes
No
Have trouble using utensils? (Fork, spoon, knife)
Yes
No
What do they prefer to drink out of?
Open Cup
Cup with Straw
Bottle with Nipple
Resist having their nails clipped?
Yes
No
Resist having their hair touched?
Yes
No
Resist having their feet touched?
Yes
No
Resist having their hair cut or brushed?
Yes
No
Resist having their teeth brushed?
Yes
No
Mobility
Does your child...
Avoid walking or running?
Yes
No
Currently or previously avoid crawling?
Yes
No
Walk on their toes?
Yes
No
Have trouble sitting still?
Yes
No
Appear more clumsy than peers? (Running into others, walls, falling often)
Yes
No
Struggle with running, riding a bicycle, or climbing?
Yes
No
Sleep
Does your child...
How many hours does your child sleep at night?
Have a hard time falling asleep?
Yes
No
Have a hard time staying asleep?
Yes
No
Have a hard time waking up in the morning?
Yes
No
School
Does your child...
Attend school or day care?
Yes
No
What school does your child attend?
What grade is your child in?
Does your child have an IEP or 504 Plan?
Yes
No
Have difficulty completing schoolwork on time?
Yes
No
Is your child easily distracted?
Yes
No
How long can your child focus on a non-electronic task?
Have difficulty with handwriting?
Yes
No
Have trouble sitting still in class?
Yes
No
Have difficulty reading textbooks?
Yes
No
Have difficulty reading from the board?
Yes
No
Play
Does your child...
Play well with others?
Yes
No
Have difficulty or lack interest in age-appropriate toys?
Yes
No
Play alone when playing with others?
Yes
No
Play too rough with others?
Yes
No
Is your child controlling when playing with others? (Always makes the rules, must win, etc.)
Yes
No
Social
Does your child...
Have trouble interacting with peers?
Yes
No
Hesitate to socialize or withdraw from play or communicating with peers?
Yes
No
Have difficulty understanding others' feelings or emotions?
Yes
No
Tend to cry easily when under stress when compared to others?
Yes
No
Express concern or worry often?
Yes
No
Often get sad, easily?
Yes
No
Engage in repetitive and self-harming behavior? (Skin pulling, hair pulling, hitting)
Yes
No
Express concerns about not being as good as their peers?
Yes
No
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.)
Yes
No
Physical Therapy
What are your main concerns in the area of Physical Therapy?
strength
balance
not keeping up with peers
Sitting Posture
Standing Posture
endurance
coordination
ball skills
walking/running
Was your child delayed in achieving any developmental milestones?
Submit
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