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 (Mother)

First Name Last Name
Parent/Guardian Name (Father)

First Name Last Name
Parent Email Address
Primary Language Spoken

English Spanish Vietnamese
Patient Sex
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?

37-40 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
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
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%
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
Should be Empty:

New Patient Registration

Patient Information

Medical History

Speech- Language History

Occupational Therapy

Daily Activities

Mobility

Sleep

School

Play

Social