Intake Form

Occupational Therapy

 
 
Patient Name *
Patient Name
Date of Birth *
Date of Birth
Parent/Guardian Name *
Parent/Guardian Name
Cell Phone *
Cell Phone
Home Phone
Home Phone
Background Information
Length of pregnancy: *
Type of Delivery: *
Did/Does your Child have Difficulty: *
Developmental History
Present level of activity: *
Behavioral Concerns:
Speech-Language Development
A quiet baby? *
A frequent crier? *
Irritable? *
Visually alert and attentive? *
Auditorily alert and attentive? *
Did you child began to babble and stop? *
At present, does your child:
Have understandable speech? *
Have a loud voice? *
Have a monotone voice? *
Have a horse voice? *
Have a stuttering problem? *
Respond to sound? *
Respond to loud sounds only? *
Seem to willingly ignore sounds? *
Medical History
Educational Background
Address *
Address
Phone *
Phone
May we contact parent/guardian by E-Mail? *
Father's Name
Father's Name
Is child/adolescent adopted? *
Please explain as needed:
Please explain if needed
Primary Address
Primary Address
Background Information
Prenatal/ Birth History
Developmental History
Developmental Milestones
Medical History