Sensory Kids New Client
Infant Feeding
Child's Name
*
First
Last
Gender
*
Male
Female
Other
Date of Birth
*
Age
*
Daycare Provider
*
Please List Preferred Days/Times for Therapy
Address
*
Street Address
City
State / Province
Postal / Zip Code
Email for Appointment Reminders
*
example@example.com
How did you hear about Sensory Kids?
Language(s) Spoken at Home
*
Health Care Provider Name and Phone Number
*
ALLERGIES
*
YES
NO
IF YES, PLEASE LIST
MEDICATIONS
*
YES
NO
IF YES, PLEASE LIST
DIAGNOSIS
*
YES
NO
IF YES, PLEASE LIST DIAGNOSIS
DATE OF DIAGNOSIS
DIAGNOSIS PROVIDED BY
Name of Physician/Provider
Please provide us with a photo copy of your insurance card (front and back). Please take a photo or upload a copy of your insurance card. Note: Please make sure this card is your child's primary insurance. As a reminder, we only accept Blue Cross Blue Shield Insurance. If your child has a primary and secondary insurance under BCBS please make note of this and let our office staff know.
Insurance Card Upload:
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Notes About Insurance:
I have the legal right to give permission for therapy services, because my relationship to the child is:
*
Custodial parent
Legal guardian
DHS caseworker
Parent/Guardian Name - Primary
*
First Name
Last Name
Parent/Guardian Preferred Pronouns
Phone Number - Primary
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email- Primary
*
example@example.com
Parent/Guardian Employer - Primary
Parent/Guardian Name - Secondary
First Name
Last Name
Phone Number - Secondary
Please enter a valid phone number.
Format: (000) 000-0000.
Email- Secondary
example@example.com
Parent/Guardian Employer - Secondary
Parent/Guardian Preferred Pronouns
Voice Message Approval
*
CHECK HERE IF IT'S OK TO LEAVE MESSAGES FOR ALL PARTIES LISTED ABOVE
Is there anything I need to know about contacting the people listed above?
Custody arrangements, divorce stipulations, etc
Emergency Contact (When neither guardian can be reached)
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship to Child
*
Please list any specialists your babe sees: (gastroenterologist, dietician, etc.):
Has your child worked with a Physical Therapist
Please Select
Currently
Past
Never
Has your child worked with an Occupational Therapist?
Please Select
Currently
Past
Never
Has your child worked with a Speech Therapist?
Please Select
Currently
Past
Never
Have you worked with a lactation consultant?
Please Select
Currently
Past
Never
Has your child done "body work" with a specialist?
Please Select
Currently
Past
Never
Please outline the mother's significant medical history below (medical diagnosis, surgeries, major or chronic illnesses, etc.)
Type a question
History of difficulty getting pregnant? If yes, please explain.
Have you been screened by a healthcare provider for post partum depression or anxiety?
Yes
No
Does the child's mother have a history of any of the following? Select all that apply.
Breast Reduction
Breast Enlargement
Breast surgery of any kind
Lung Surgery
Heart Surgery
Trauma to the chest
Does your child have siblings? If so please list ages:
Do you have family or friends who help provide care for your child?
Describe your reason for seeking our services for feeding, how long has this reason influenced you/your life/when did you first notice feeding difficulties?
Has your child had a Modified Barium Swallow Study (MBSS)? If Yes, when and what were the results.
Does your child have a history of reflux?
Yes
No
Does your child have a feeding tube?
If a feeding tube is present, please outline the method of feeding (gravity, pump), time of feedings, frequency and volume of feedings.
Labor and Delivery Information
*
Born Full-Term
Born Premature
Vaginal
C-section birth
Childs Birth Weight
*
Gestational Age
*
By Week
Please describe any pregnancy complications
*
My child is currently
Breastfed
Bottle Fed
Combination
Neither
What difficulties are you facing with breast feeding?
What difficulties are you facing with bottle feeding?
What have you tried to do to resolve the feeding challenges on your own? In what way(s) was this helpful?
How many times a day does your child feed?
Does your child eat at night and if so, how often?
If bottle feeding, select all that apply.
using pumped breastmilk
using formula
using a mix of formula and breastmilk
Describe how much formula and/or breastmilk your child is taking in daily. If exclusievly breastfeeding, how many times a day and for about how long is each time your child is nursing?
If offering formula, which brand are you using and how is baby tolerating it?
If pumping, how many times a day are you pumping? How long is an average pump session and how much milk is expressed on average?
Have solids been introduced?
Yes
No
If yes, what age were solid foods introduced?
Any issues with solid foods not described above?
Please list all the people who feed your baby (example: mother, father, nanny, etc.)
Does your baby have regular bowel movements?
Yes
No
If no, please explain.
List hospitalizations, surgeries, and injuries (broken bone, tonsillectomy, concussion, etc) with dates
Recent testing not outlined above (MRI, swallow study, x-rays, hearing test, ADHD, IQ, genetic testing, etc.)
Please share anything you think is important for us to know that we may have missed:
Did child pass newborn hearing screening?
*
YES
NO
Has your child had a history of ear infections or tubes placed.
*
Parent/Guardian Signature
Submit
Should be Empty: