Medical Intake Form Step 1 of 10 10% Parent/Guardian First Name:* Parent/Guardian Last Name:* Phone Number:*Email Address:* Street Address:* City:* State:*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZIP Code:* GENERAL INFORMATIONChild's Name* First Last Date of Birth* MM slash DD slash YYYY Insurance Plan Name:* Please list all parents/caregivers.*NamePhone NumberEmail Click (+) on the right to add rows.Current concerns:*Support Coordinator Name: First Last Support Coordinator Phone Number: FAMILY HISTORYChild lives with:* Birth Parents Parent and Step-Parent One Parent Adoptive Parents Foster Parents If divorced, is it joint custody? Yes No Can we communicate with both parents? Yes No Are we able to communicate with the step-parent? Yes No Is there anything special about child's living situation we should know?Other children in the family:NameAgeGenderSpeech/Hearing Difficulties/Diagnosis Click (+) on the right to add rows.Has any immediate or extended family member experienced the following? Hearing Problems Learning Problems Cognitive Delay Seizure Disorder Congenital Disorder Autism Stuttering Describe:What is the primary language spoken in the home?* English Spanish Russian Chinese Hindi Are any other languages spoken in the home?* Yes No List other language(s) spoken in child's home. PREGNANCYPlease select any issues experienced by child's birth mother. Bleeding Excessive Weight Gain Limited Weight Gain Toxemia Seizure Disorder Maternal Medications Maternal Drug/Alcohol Use Pre-Term Labor Gestational Diabetes Infections Multiple Birth Please list maternal medications. DELIVERYPlease select all that apply to the birth mother's delivery. Difficult Birth Prolonged Labor Breech Birth Brief Labor Cesarean Sections Baby treated for jaundice Baby had respiratory distress Oxygen needed for baby Cord around baby’s neck Umbilical cord knot Other Other complications: Were any of the following used during delivery? Epidural Forceps Vacuum Suction Length of pregnancy (in weeks): Baby's weight (lb., oz.): Days in the hospital before discharge: NEWBORN/NURSERYSelect any that applied when child was a newborn: NICU Stay Sucking Difficulties Breathing Machine Brain Bleed Length of stay in NICU: Reason for stay: Grade level of brain bleed: I II III IV I don't know. Was the brain bleed resolved? Yes No MEDICAL HISTORYSelect all that apply to the child's medical history. Adenoidectomy Allergies Anxiety Asthma/Reactive Airway Disease Chronic Ear Infections Cleft Lip/Palate Depression Ear Tubes Encephalitis Failure to Thrive Head Injury Heart Problems High Fevers Lung Problems Measles Meningitis Mumps Pneumonia Scarlet Fever Seizures Surgeries Thumb/Finger Sucking Tonsillitis/Tonsillectomy Other Other: List allergies: Other hospitalizations: Is the child on any medications?* Yes No List the name, dosage, and frequency of medications.Primary care physician name: Primary care physician's phone number:Primary care physician's office address: Adaptive equipment/assisted technology: Does the child have a medical diagnosis?* Yes No List and describe all of the child's medical diagnoses.Are immunizations up to date?* Yes No If not, please explain. Do you have any concerns with your child’s vision? Yes No Does your child wear glasses? Yes No Date of last vision screening: MM slash DD slash YYYY Do you have any concerns with your child’s hearing? Yes No Date of last hearing screening: MM slash DD slash YYYY Do you have any concerns regarding your child's oral health? Yes No Date of last dental examination MM slash DD slash YYYY Select all specialists your child has seen or is currently seeing: Allergist Behavior Specialist Cardiologist Dietician Gastroenterologist Neurologist Occupational Therapist Pulmonologist Physical Therapist Psychologist/Psychiatrist Speech-Language Pathologist Other Other: DEVELOPMENTAL HISTORYAt what age did your child do the following? Indicate “N” if they have not yet accomplished it. COMMUNICATION Cooed/babbled First word Followed 1-step direction Used two words together GROSS MOTOR Head control Rolled both ways Sat on his/her own Crawled Walked Jumped Hopped on one foot Rode bike FINE MOTOR Pointed with index finger Finger feed Ate with spoon Cut with scissors Drew a circle Removed clothing Put on clothing Put on shirt independently Buttoned independently Zipped independently Toilet trained Combed hair Bathed independently Tied shoes EDUCATIONAL HISTORYDid or does your child attend pre-school? Yes No What grade is your child in?What is the name of your child’s school? What district is the school in: Child is in: General education Resource Self-contained What is the child’s teacher’s name? Is it OK to contact the teacher? Yes No Does the child receive the following services in school?Select all that apply. Speech OT PT Adaptive P.E. Social Work Any concerns with academic skills? Yes No Any concerns with social skills? Yes No Hand preference: Right Left Not established Difficulty with handwriting? Yes No BEHAVIORAL HISTORYPlease select all behavioral characteristics. Aggressive Avoids certain textures/temperatures Cries, screams often Difficulty transitioning (to activities, places) Distracted/avoidant of loud noises Engages in repetitive behaviors High activity level Impulsive regularly Plays with others Poor eye contact Prefers to play alone Property destruction Seeks/avoids movement Self-injurious behavior Short attention Transitioning (to activities, places) Uncooperative Walks on tip-toes Willing to try new things Withdrawn List all textures/temperatures the child avoids. CURRENT COMMUNICATIONSelect all that apply to the child. Repeats sounds, words, or phrases over and over Understands what you are saying Retrieves/points to common objects upon request Follows simple directions Responds correctly to yes/no questions Responds correctly to "Wh-" questions (what, where, why, who, when) What does your child currently use to communicate? Joint attention Sounds (vowels, grunting) Words 2-4 word phrases Sentences Augmentative Communication Device Other Other: FEEDING DEVELOPMENTDo you have concerns regarding the child’s feeding skills? Yes No Please describe your concerns.Does the child have any food allergies? Yes No Please list child's food allergies and describe reactions (if known).What foods does the child eat?Include type, texture, baby food, table food, etc.Where does the child usually eat? Highchair Table Lap Does the child have any history of difficulty taking the breast/bottle? Yes No If yes, please explain.Does the child have any history of reflux or issues associated with feeding? Yes No If yes, please explain. FAMILY CONCERNS AND EXPECTATIONSWhat are some of the child’s strengths and interests?What are your concerns about the child?What do you hope to gain for the child and yourself/family from this program?Are you interested in information regarding social services (ex: psychology/family counseling, grief counseling)? Yes No Which service(s)? Has the child ever been enrolled in any of the following private therapy programs? Speech/Language Therapy Physical Therapy Occupational Therapy ABA/Behavior Therapy Psychology/Counseling/Social Work Social Skills Group Please explain reason for private therapy.Please indicate the agency/program, city/state, date range of therapy, and services received.Speech Therapy# Min. per weekCurrent or past date rangeApprox. date of last evaluation ABA/Behavior Therapy# Min. per weekCurrent or past date rangeApprox. date of last evaluation Physical Therapy# Min. per weekCurrent or past date rangeApprox. date of last evaluation Occupational Therapy# Min. per weekCurrent or past date rangeApprox. date of last evaluation Psychology/Counseling/Social Work# Min. per weekCurrent or past date rangeApprox. date of last evaluation Social Skills Group# Min. per weekCurrent or past date rangeApprox. date of last evaluation CONSENTDo you give consent for an evaluation and/or therapies to be provided by EBS Children’s Institute of Oxford?* Yes No Do you consent to obtain any evaluations/documentation in person per our standard method of delivery? If not, your evaluation will be mailed to you at the address provided.* Yes No Date MM slash DD slash YYYY