Patient Intake
Please fill out the form completely:
Patient Information
Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Male
Female
BIrthdate
-
Month
-
Day
Year
Date
Current Age
Social Security Number
Diagnosis
Who referred you to us?
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Parent/Legal Guardian Information
Relationship to Patient
Mother
Father
Other(Guardian, Foster Parent, etc.)
Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Employer
Work Phone
-
Area Code
Phone Number
Social Security Number
Policy Holder for Patient
Yes
No
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Primary Insurance Information
Name of Insurance Company
Effective Date
-
Month
-
Day
Year
Date
Policy Number
Group Number
Subscriber's Name
Social Security Number
Subscriber's Birthdate
-
Month
-
Day
Year
Date
Relationship to Patient
Mother
Father
Other(Guardian, Foster Parent, etc.)
Does your insurance require pre-authorization?
Yes
No
Parent / Guardian Initials
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Secondary Insurance Information
Do you have secondary insurance?
Yes
No
Name of Insurance Company
Effective Date
-
Month
-
Day
Year
Date
Policy Number
Group Number
Subscriber's Name
First Name
Last Name
Social Security Number
Subscriber's Birthdate
-
Month
-
Day
Year
Date
Relationship to Patient
Mother
Father
Other(Guardian, Foster Parent, etc.)
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Medical History
Reason for visit:
Current Medications:
Allergies:
Has this child had an operation?
Yes
No
If "yes" explain for what:
Parent / Guardian Initials
Has this child had a bad or unusual (allergic) reaction to any foods or drugs?
Yes
No
If "yes" explain for what:
Has this child ever had any one of the following illnesses/ problems?
Allergy / Asthma
Heart Condition
Bleeding Problems
High Blood Pressure
Cancer / Tumor
Kidney Trouble
Deafness
Diabetes Problems
Epilepsy (Fits, Seizures)
Vision Problems
Painful or Swollen Joints
Unusual Bruising or Bleeding
If "yes" explain for what:
Have you been seen elsewhere this year for Occupational, Physical or Speech Therapy?
Yes
No
Name of Clinic or Hospital
Therapist Name
First Name
Last Name
Clinic/Hospital Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Type of Therapy
How Often
Currently been seen else?
Yes
No
Date of Last Visit
-
Month
-
Day
Year
Date
How many times have you been seen this calendar year for Occupational Therapy?
How many times have you been seen this calendar year for Speech Therapy?
Parent / Guardian Initials
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Primary Physician
Name of Doctor's office
Doctor's Name
First Name
Last Name
Office Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
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Developmental History
Age when child: (If you cannot remember specific time, please indicate if it occurred at the expected time or if it was delayed)
Sat Up Alone
Crawled
Walked
Toilet Trained
Dressed Self
Tied Shoes
Fed Self-Independently
Weaned from Bottle/Breat
Is the child able to open cups?
Yes
No
Is the child able to use spoons?
Yes
No
Is the child able to use straws?
Yes
No
Right or Left Handed
Right
Left
Any difficulty swallowing?
Yes
No
Any difficulty chewing?
Yes
No
Any difficulty drinking?
Yes
No
Any difficulty blowing?
Yes
No
Any difficulty drooling?
Yes
No
Any difficulty food allegeries?
Yes
No
Favorite foods:
Aversive foods:
Attention Span for Self-Directed Activities:
Attention Span for Adult-Directed Activities:
Eating Sleeping Patterns
Does your child respond to light?
Yes
No
Does your child respond to sound?
Yes
No
Does your child respond to people?
Yes
No
Does your child play well with others?
Yes
No
Who?
Eat and sleep well?
Yes
No
Cry appropriately?
Yes
No
Laugh?
Yes
No
Smile?
Yes
No
Make wants/needs known?
Yes
No
How?
Does you child show unusual behavior?
Parent / Guardian Initials
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Language Development
Age when child first spoke?
Combined Words?
Spoke in Sentences?
Child's first word?
First Sentence?
Mispronounce any sounds?
Which ones?
How many words can your child say? (If fewer than 15, please list)
How long are your child's sentences?
Does your child have difficulty following directions?
Doe syour child have difficulty understanding you?
Do any immediate family members have speech or hearing difficulties?
Parent / Guardian Initials
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Social Development
Names and ages of sibling:
Adults living in the home:
Moves prior to age 10:
Relationships with peers:
Number of regular playmates:
Ages:
Genders:
Activities shared with parents and siblings:
How does your child handle frustration?
Conflict?
Separation?
Regular responsibilities?
What are your child’s favorite places?
Toys?
People?
Places?
Snacks?
Activities?
Television Programs/Movies
What motivates your child most?
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School History
Child’s current school:
Child’s current grade:
Child’s educational performance:
Receiving special education services at school:
How does your child’s teacher describe his/her performance?
Has the teacher expressed any concern? (please explain)
Parent / Guardian Initials
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Other
What do you hope to have happen as a result of the evaluation:
Does the report need to be sent to specific agencies?
Yes
No
Where?
Is there any other information that you would like us to be aware of?
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Contact Information
At times we may need to contact you for appointment reminders or other concerns. Please complete only the items below that you authorize as a method of contact.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone
-
Area Code
Phone Number
Mother's Cell Phone
-
Area Code
Phone Number
Mother's Work Phone
-
Area Code
Phone Number
Mother's Email
example@example.com
Father's Cell Phone
-
Area Code
Phone Number
Father's Work Phone
-
Area Code
Phone Number
Father's Email
example@example.com
Which phone number would you prefer us to leave messages on?
Please select our preferred contact method (one only) for each item listed below:
Phone
Mother's Email
Father's Email
Parent / Guardian Initials
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Parental/Birth History
Full Term?
Yes
No
If no, How many weeks?
Birth Hospital:
Illnesses or accidents during pregnancy:
Use of alcohol, tobacco or medications during pregnancy:
Birth weight:
Length:
Delivery method: (Check all that apply)
Vaginal
Cesarean
Breech
Was your child taken to NICU after birth?
Yes
No
Please describe any complications that occurred during pregnancy, birth or after deliver:
Parent / Guardian Initials
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