Mobi Healthcare - Participant Intake Form

  • INITIAL Paediatric Participant Intake Form

  • This is a detailed intake form, so please allow 10 minutes to complete. Only answer questions that apply to your child.

  • 1. Parent/Carer Details

  • PARENT/ CARER 1 DETAILS

  • PARENT/ CARER 2 DETAILS

  • 2.1 Participant's Details

  • Date of Birth*
     - -
  • Does your child have a known degenerative or progressive health condition?

  • 2.2 Funding

  • What type of funding will you use?*
  • Category*
  • Format: 0000-000-000.
  • Do you have a support coordinator?*
  • Format: 0000-000-000.

  • 2.3 Mobi Paediatric Therapy Services

  • Please select all service(s) you are requesting?

  • PHYSIOTHERAPY

  • Therapy Frequency
  • Preferred start date?
     - -
  • Are you interested in intensive therapy? (Intensive therapy involves a high frequency of therapy over a short duration of time. Based upon a client’s age, diagnosis, and goals, an intensive physiotherapy program involves 5 days a week for 2-3 weeks)

  • OCCUPATIONAL THERAPY

  • Do you prefer your session to be in the:
  • Here is the list of available OT services you can choose from. Please select the service(s) you are looking for.

  • SPEECH THERAPY

  • Are there other languages other than English spoken at home?*
  • What would you like your speech therapy session to focus on?
  • Therapy Frequency
  • Preferred start date?
     - -

  • 3.1 General Information

    Pregnancy and Birth History
  • Were there any complications, illnesses or stress during pregnancy?
  • Were there any complications, illnesses or stress during labour and delivery?
  • Please specify the conditions of your child's birth

  • 3. General Information

    Medical History
  • Has your child experienced any major injuries or hospitalisations?*
  • Does your child have allergies or anaphylaxis?*
  • If yes, do you have an anaphylaxis management plan in place?*
  • Does your child have a history of seizures?*
  • If yes, do you have a seizure management plan in place?*
  • Does your child have a history of lung conditions (including asthma)?*
  • If yes, do you have a asthma management plan in place?*
  • Does your child have a history of heart problems?*
  • Does your child have a history of kidney problems?*
  • Does your child have history of bone density issues or history of fractures?*
  • Does your child have a G-tube/ J-tube/ PEG?*
  • Does your child have any history of concerns of scoliosis (curvature in the spine)?*
  • Are your child's hips regularly monitored?*
  • Is there any history of hip subluxation or dislocation?*
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  • Has your child had their vision assessed?
  • Does your child wear glasses?
  • Does your child have a history of ear infections?
  • Has your child had their hearing tested?
  • Does your child wear a hearing aid?
  • Does your child wear specific supportive shoes?
  • Does your child currently have AFOs or other orthotics?

  • 4. Social History

  • 5. Therapy History

  • Please select or specify the therapy your child is currently attending

  • 5.1 PHYSIOTHERAPY

  • 5.2 OCCUPATIONAL THERAPY

  • 5.3 SPEECH THERAPY

  • 5.4 OTHER THERAPIES

  • 6. Milestone History

    Tell us the approximate age your child achieved the following skills

  • 7. Movement Skills

  • Does your child become overly excited over movement activities?
  • Does your child like to be wrapped tightly in a sheet/ blanket or seeks tight spaces?
  • Does your child display the following movement difficulties? Tick all that applies to your child.

  • 6. Feeding

  • Was your child breastfed as an infant?
  • If your child was bottle fed, were there any difficulties or concerns?
  • Did your child have a strong suck reflex as a child?
  • Did your child frequently spit up as an infant or have reflux?
  • Did your child have problems with appetite or weight gain as an infant?
  • Did your child have respiratory problems as an infant?
  • How is your child currently fed?
  • Which behaviours are noted during feeding?
  • Does your child attempt to eat unusual, noxious or inedible substances or place in mouth?
  • Does your child have a history of:

  • 7. Social Interaction and Communication

  • Does your child exhibit aggressive behaviour?*
  • Does your child exhibit tantrums?*
  • Is your child easily frustrated, anxious or overwhelmed?*
  • If your child uses atypical repetitive behaviour, which behaviours are demonstrated?
  • Is your child willing to try new activities?
  • Does your child struggle when there is excessive auditory input in their environment?
  • Does your child have difficulty meeting new people?
  • Does your child struggle to communicate their own needs?
  • Is your child able to follow simple directions?*
  • Does your child use:
  • How often does your child make eye contact during conversation?
  • How often does your orient to his/ her name being called?

  • 10. Play Skills

  • How long is your child able to play alone?
  • Does your child struggle playing with children?

  • 8. Aspirations and Expectations

  • 9. NDIS Plan Goals

    Please copy and paste your NDIS Goals here or upload NDIS plan in section 10. This is required to write your child's NDIS reports and for goal setting.

  • 10. Attach your files

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  • Date*
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