Occupational Therapy Intake Form

Child's Name

Today's Date

Sex

M F

Child's Birthday

Age

Address

City

Zip Code

Home phone

Mother’s Name

Mother's Age

Mother's Occupation

Mother's Cell

Mother's Work Number

Father's Name

Father's Age

Father's Occupation

Father's Cell

Fahter's Work Number

Does the child live with both parents?

Pediatrician

Phone

Address

Medical Diagnosis

Child's School

Grade

Is your child receiving any other therapy services?

Is your child participating in any social/community activities?

What are your child’s favorite play interests?

Developmental Team

Allergist's Name, Dates Seen and Findings

Audiologist's Name, Dates Seen and Findings

Developmental Optometrist's Name, Dates Seen and Findings

Gastroenterologist's Name, Dates Seen and Findings

Neurologist's Name, Dates Seen and Findings

Nutritionist/Dietitian's Name, Dates Seen and Findings

Occupational Therapist's Name, Dates Seen and Findings

Ophthalmologist's Name, Dates Seen and Findings

Physical Therapist's Name, Dates Seen and Findings

Psychiatrist's Name, Dates Seen and Findings

Psychologist's Name, Dates Seen and Findings

Speech Pathologist's Name, Dates Seen and Findings

Pregnancy

Any complications/health problems? If yes, please explain below.

Yes No

Any emotional trauma or stress? If yes, please explain below.

Yes No

Any Medications during pregnancy? If yes, please explain below.

Yes No

Was the mother physically active? If no, please explain below.

Yes No

Was bed rest recommended? If yes, please explain below.

Yes No

Any exposure to smoke or alcohol? If yes, please explain below.

Yes No

Pregnancy comments

Please check your answers above and provide further details if required. Feel free to add anything else you think we should know about the pregnancy.

Labor/Delivery

Was delivery full term? If no, please explain below.

Yes No

If not full term, gestational age?

Yes No

Vaginal delivery? If no, please explain below.

Yes No

Induced Labor?

Yes No

Forcep or vacuum assist?

Yes No

Caesarean birth?

Yes No

C Section Planned? If yes, give reason below

Yes No

C Section Emergency? If yes, please give reason below

Yes No

Oxygen assist necessary? If yes, please explain below

Yes No

Delivery Position (e.g. breech)

Structuraly abnormalities? (cleft lip, etc) If yes, please explain below

Yes No

Labor/Delivery comments and explanations

Birth weight

APGAR Score

Any additional complications? (i.e. jaundice, difficulty feeding, weight loss, delayed discharge from hospital):

Developmental Milestones: please note when each one occurred

Roll Over

Sit Up

Crawl

Walk

Drink from a cup

Feed Self

Toilet Trained

What is the frequency of BMs?

Constipation or loose bowels

Constipated Loose

Stomach Aches?

Yes No

Was crawl phase brief?

Yes No

Friendships: check all that apply, explain below any item you checked.

Please indicate how your child relates to other children

Has problems relating or playing with other children?

Fights frequently with playmates?

Prefers playing with younger children?

Has difficulty making friends?

Prefers to play alone?

What role does your child take in peer group games? ( i.e. leader, aggressor, follower)

Please explain anything you checked above.

Medication

Please list the medications your child takes, the dosage, frequency of administration and reason for taking.

Have there been any negative reactions to medications? If yes, please identify

Please explain anything you checked above

Please explain any item checked. Add the year and age it happened.

Childhood Development

Which hand does your child use for writing or drawing?

Which hand does your child use for eating?

Which hand does your child use for throwing, catching, etc.?

If your child uses both hands, which is most preferred?

How well did your child cut in Preschool/Kindergarten?

Poor Fair Good Excellent

How well did your child glue in Preschool/Kindergarten?

Poor Fair Good Excellent

How well did your child color in the lines?

Poor Fair Good Excellent

From the age of five to the present time, were/are there any special problems noted in the following areas? If yes, please describe.

Difficulty learning how to ride a bike?

Yes No

Difficulty learning to skip?

Yes No

Difficulty following directions?

Yes No

Difficulty following multiple directions?

Yes No

If yes to any above, please describe

Hearing, Auditory, Balance, Coordination & Visual Processing

Please explain your primary concerns for referring your child (concerns, difficulties, questions, etc.)

Has your child ever had his/her hearing tested?

Yes No

If yes, date of test and results

Have you ever noticed a problem with your child’s hearing?

Yes No

Has your child ever had his/her vision tested?

Yes No

If yes, date of test and results

Have you, your family, or your child’s teachers noticed your child having difficulties with vision?

Yes No

If yes, please describe

Does your child demonstrate the following qualities? If no, please describe.

Good balance

Yes No

Good coordination

Yes No

Good handwriting?

Yes No

Clumsiness?

Yes No

Ability to perform the same physical tasks as age matched peers?

Yes No

Please describe any item above that was marked 'No'

What sports does your child enjoy?

Hobbies?

What other activites does your child enjoy?

Does your child sleep through the night?

Yes No

On average, how long does it take for your child to fall asleep?

Please describe any concerns you have for your child’s sleeping habits or bedtime routine

Your information will be encrypted.