Occupational Therapy Intake Form

Please correct the errors described below.

Developmental Team

Pregnancy

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

Developmental Milestones: please note when each one occurred

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

Medication

Childhood Development

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

Hearing, Auditory, Balance, Coordination & Visual Processing

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

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