New Patient Intake Form
Patient Name
*
First Name
Last Name
Birth Date
*
-
Month
-
Day
Year
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Gender
Please Select
Male
Female
School & Grade
Parent /Guardian
*
First Name
Last Name
Email
*
example@example.com
Cell Phone
*
Please enter a valid phone number.
Parent / Guardian
First Name
Last Name
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Patient lives with:
*
Both Parents
Mother
Father
Foster Parents
Adoptive Parents
Step Parent
Other
Current Residence Information
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Other Children in the Family
Age
M/F
Grade
Developmental Concerns
Name
Name
Name
*
Primary Language Spoken in Home
Other Languages Spoken in Home
Any Cultural Influences in the Home or Family
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Notes
Birth History
*
Was your baby breast fed and/or bottle-fed
Breast fed
Bottle - fed
Both
Did your child have any difficulty with breast feeding or bottle feeding?
No issues
Difficulty Latching
Coughing
Crying
Reflux
Gagging
Other
Was a lip-tie or tongue-tie identified?
Yes
No
If yes, was their a revision or release?
Approximately at what age rolled?
Approximately at what age crawled
Approximately at what age walked
Approximately at what age babbled
Approximately at what age said first words
Approximately at what age put 2 words together
Approximately at what age toilet trained
List any current medications
Allergies to medications or foods
Describe your child's health concerns
Describe behavioral concerns
Has your child been seen by a dentist?
Yes
No
Does the dentist have concerns about structure?
High palate
Lip-tie
Tongue-tie
Crowding
Teeth grinding / Bruxism
Spaces between teeth
Therapy History
Did your child receive early intervention services, if yes indicate type of services and duration
*
Did your child receive any out patient therapy services the previous year? If yes indicate type of therapy and location
*
School Information
Any Services received at School?
*
Physical Therapy
Occupational Therapy
Speech Therapy
Other
Comments / Concerns about School Services
Childs Interests
*
Family Goals with Therapy
Sensory Feeding / Oral Motor
*
Does your child refuse new food / textures?
Does your child eat a very limited diet for their age? i.e. 10 foods or less
Does your child drool excessively?
Does your child have food aversions? i.e difficulties with taste, texture, temperature, color
Does your child have difficulty using a straw?
Does your child have difficulty using a cup?
Does your child refuse to have his/her teeth brushed
Does your child refuse to touch food with his/her hands?
Does your child always have something in his/her mouth, or is chewing on clothes or fingers?
N/A
Hearing
*
Bothered by household sounds? such as toilet, vacuum, etc..
Holds hands over ears to avoid sounds?
Distracted by environmental / background noises?
Appears to tune out what is said despite good hearing?
Seems to talk excessively or makes noises more than others
Difficulty following verbal directions?
N/A
Vision
*
Bothered by busy visual environments
Avoids eye contact, fleeting eye contact
Highly focused on objects rather than people. i.e objects that spin, light up, letters, numbers, shapes
Difficulty copying shapes, numbers or letters from paper or board
Does not notice when people enter a room or changes in details
N/A
Tactile Sensation
*
Aversion to fabrics, seems or tags in clothing?
Dislikes being messy
Dislikes being cuddled or hugged
Dislikes hygiene routines such as brushing hair/teeth, nail clippings, haircuts
Walks on toes
Unusual need for touching surfaces or textures
N/A
Emotional / Behavioral
*
Becomes easily frustrated
Outbursts, i.e self harm, aggression, excessive emotions.
Difficulty getting along with others
Difficulty with changes to routines
Impulsivity
Withdraws from social situations
N/A
Gross motor
Difficulty with hopping, jumping, running or skipping
Difficulty with riding a bike
Tends to confuse right and left
Hesitant to play on outdoor equipment or on team sports
Unsafe risk taking, i.e moving and climbing with no safety awareness
Slouches when sitting
Sits on knees, or has "w" shape to legs when on the ground
Favors one side of the body over another
Clumsy, bumps into things, falls down easily
Fine motor
Difficulty with buttons/zippers/snaps/etc.
Unable to tie shoes
Difficulty with drawing, coloring, copying and/or cutting
If school age, unable to write name or poor handwriting, fatigues during written tasks
Poor grip on utensils
Only eats with hands
Unable to use hands for playdoh, sand play, scooping, grabbing of small objects, building blocks, etc.
Poor hand/eye coordination
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