Occupational Therapy Intake Step 1 of 4 25% Parent/Guardian First Name*Parent/Guardian Last Name*Phone Number*Email Address* Patient's Name* First Last What are your primary concerns/goals for occupational therapy regarding your child?*What are your child’s strengths?*What are some of your child’s favorite things? Favorite play activities? Please list any favorite characters, such as super heroes or cartoon characters, or any types of favorite song artists, as applicable.*What makes your child happiest?*Hand Preference:*RightLeftBothUnknownDoes your child receive school-based therapy? OT (Occupational Therapy) PT (Physical Therapy) Speech and Language Does your child receive special instruction or have an established IEP?*YesNoDoes your child have a 504 Accommodation Plan?*YesNo Medical HistoryRemarkable diagnoses:*Known food allergies:*Special diet (i.e. gluten free, pureed food only, tube feeding, etc.):*Medical precautions:*Currently receiving services from other health care professionals: Psychologist PT (Physical Therapist) Speech and Language Therapist Nutritionist Behavioral Specialist Other Other: Developmental HistoryPlease check all the developmental milestones that your child has achieved: Rolling Sitting alone Creeping on all fours Pull to stand Walking Eating with a spoon Hopping on one foot Finger feeding Cutting with a knife Cutting with scissors Jumping Riding a bike Developmental milestones were:*Met within typical age rangesDelayedAreas of special concern regarding developmental milestones:*Please select the amount of assistance needed for your child to complete the following. Using spoonNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpUsing forkNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpUsing knifeNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpPuncturing straw in drinkNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpGroomingNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpBrushing teethNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpBathingNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpUpper dressingNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpLower dressingNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpSnapsNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpShoes onNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpShoes offNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpTying shoesNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpSocks onNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpSocks offNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpToiletingNo help neededOnly needs supervisionNeeds 25% helpNeeds 50% helpNeeds 75% helpNeeds 100% helpOther concerns:Please select if you would describe the following as remarkable for your child: Mostly quietYesNoSometimesNot applicableOverly activeYesNoSometimesNot applicableTires easilyYesNoSometimesNot applicableTalks constantlyYesNoSometimesNot applicableToo impulsiveYesNoSometimesNot applicableRestlessYesNoSometimesNot applicableClumsyYesNoSometimesNot applicableNervous ticks/habitsYesNoSometimesNot applicableWets bedYesNoSometimesNot applicablePoor attentionYesNoSometimesNot applicableFrustrated easilyYesNoSometimesNot applicableUnusual fearsYesNoSometimesNot applicableRocks self frequentlyYesNoSometimesNot applicableMostly quietYesNoSometimesNot applicableStubbornYesNoSometimesNot applicableResistant to changeYesNoSometimesNot applicableFights frequentlyYesNoSometimesNot applicableUsually happyYesNoSometimesNot applicableExhibits temper tantrumsYesNoSometimesNot applicableDifficulty falling asleepYesNoSometimesNot applicableDifficulty staying asleepYesNoSometimesNot applicableSluggish in the morningsYesNoSometimesNot applicableIf yes to any above, please describe. Social and Occupational HistoryPlease check how you would describe the following for your child. Socializes with family and close friends?OftenSometimesRarelyNot applicableCommunicates needs and wants effectively?OftenSometimesRarelyNot applicableHard to make friends?OftenSometimesRarelyNot applicableTends to interact/play with younger children?OftenSometimesRarelyNot applicableEnjoys time alone?OftenSometimesRarelyNot applicableTolerates change in routine?OftenSometimesRarelyNot applicableTolerates running errands?OftenSometimesRarelyNot applicableEnjoys eating in restaurants?OftenSometimesRarelyNot applicableEnjoys attending birthday parties?OftenSometimesRarelyNot applicableEnjoys attending family gatherings?OftenSometimesRarelyNot applicablePlease provide any additional information that you would like to share about your child.Person completing this intake form: First Name Last Name Relationship to child:
