Pediatric Intake Form – Advanced Occupational Therapy Services

Date *

Pediatrician *

Child's Name *

Birthdate *

Sex *

Age *

Parent's Name *

Contact Phone Number *

Address *

Email Address *

School Attending *

Grade / Level *

Teacher's Name *

School Phone Number *

Allergies: Please list any medication or foods that your child is allergic to (i.e. latex, peanuts, etc.):

Please list any prescription medications your child is taking:

Does your child currently have any diagnoses? Please list:

Please check any of the following evaluations/assessments that your child has received:

Physical Therapy Evaluation

Speech Therapy Evaluation

Psycho educational Evaluation

Vision Therapy Assessment

Please list any surgeries, injuries, illnesses or hospitalizations your child has had to date:

Please check any of the following whose care your child is under:

Does your child receive any of the following services at school?

Please describe the issue of concern at home and/or school, which has facilitated this evaluation:

Background Information

Complications, illness/infections during pregnancy? Y / N (describe)

Complications during labor and delivery? Y / N (describe)

Forceps / Vacuum / C-section? Y / N (elaborate)

Birth Order

Birth Weight

Pre-Mature/Post-Mature/Full-Term?

Pre-Mature

Post-Mature

Full-Term

Breast Fed?

Yes

No

How long?

Strong suck?

Yes

No

Spit up frequently?

Yes

No

Problems with Feeding/Respiration/Sleeping? (describe)

Irritable/Happy/Quiet Baby?

Irritable

Happy

Quiet

Did baby arch back & head when upset?

Yes

No

Developmental Milestones

Please note approximate age at which he/she did the following:

Sat

Belly Crawled

Crawled

Cruised

Walked

Said First Words

Talked

Undressed Self

Toilet Trained (Bladder & Bowels)

Dressed Self

Managed Snaps, Zippers, Buttons

Tied Shoes

Started Pre-school

Ear Infections? Y / N (How many, at what ages?)

Seizures? Y / N (describe)

Glasses? Y / N (If yes, please explain the type of prescription:)

Has the child had his or her vision checked within the past year?

If no, when was the last time the vision was checked and what were the results?

Age(s) and sex (es) of siblings

Age established?

Preferred hand?

Left

Right

No preference

General Comments