Intake Questionnaire Date:___________ Child’s Legal Name:_________________________________
My child goes by: _________________
Date of Birth:__________________________________
Male____
Female____
Street: _______________________________ City:__________________ State:____________ Zip:_________ Completed by:_________________________________
Relationship_____________________
Demographic Information: Parent/Guardian 1 Name: _______________________________ Address: Same as child (circle): Yes
No: If different, please complete:
Street: _______________________________ City:__________________ State:____________ Zip:_________ Home Phone: ____________________ Cell: ____________________ Work: ____________________ E-mail: ________________________________________________ Parent/Guardian 2 Name: _______________________________ Address: Same as child (circle): Yes
No: If different, please complete:
Street: _______________________________ City:__________________ State:____________ Zip:_________ Home Phone: ____________________ Cell: ____________________ Work: ____________________ E-mail: ________________________________________________ I was referred by:_________________________________________________ Reason for Referral:
What do you hope to achieve from services at this clinic?
Primary Physician’s Name: ________________________________________________ Practice Name: ________________________________________________ Office Phone: ____________________ Office Fax: ____________________ Medical Diagnosis of Child: ________________________________________________
Is your child currently receiving any therapy? (circle): Yes No Has your child received therapy in the past? (circle): Yes
No
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School Information Current School/Daycare (morning): ________________________________________________ Primary Teacher: ______________________________ Grade: ____ Type of Classroom: ___________________ Office Phone: ____________________ Office Fax: ____________________
Current School/Daycare (afternoon): ________________________________________________ Primary Teacher: ______________________________ Grade: ____ Type of Classroom: ___________________ Office Phone: ____________________ Office Fax: ____________________
Current Therapy Provider(s)* Therapy Type (please circle): OT
SLP Mental Health Developmental Social/Play Group Other: ______
Name: __________________________________ Phone: _______________ Therapy Type (please circle): OT
SLP Mental Health Developmental Social/Play Group Other: ______
Name: __________________________________ Phone: _______________ Therapy Type (please circle): OT
SLP Mental Health Developmental Social/Play Group Other: ______
Name: __________________________________ Phone: _______________
Past Therapy Provider(s)* Therapy Type (please circle): OT
SLP Mental Health Developmental Social/Play Group Other: ______
Name: __________________________________ Phone: _______________ Therapy Type (please circle): OT
SLP Mental Health Developmental Social/Play Group Other: ______
Name: __________________________________ Phone: _______________
*Please use the back of this sheet if more room is required.
Family History Siblings: Name
Birth Date
Sex
General Health
Physical Challenges
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Educational Challenges
Please check if a member of the family has any of the following: Speech-language disorder(s): ____ Autism/Spectrum Disorder: ____ ADD/ADHD: ____ Developmental Delay(s): ____ Sensory Integration problems: ____ Learning Disabilities: ____
Genetic Disorder(s): ____ Depression: ____ Anxiety: ____ Bipolar Disorder: ____ Other: ___________ Other: ___________
Birth History Please describe any unusual pregnancy experiences or complications:
Medications taken during pregnancy: Drugs or anesthetics during labor: Type of delivery (circle): Vaginal Delivery complications:
C-Section
Breech
Forceps
Length of pregnancy (in weeks): ____ Duration of labor (in hours): ____ Birth weight: ________ APGAR rating: ____ Adopted (circle): Yes No If adopted, age of adoption: ____ Birth country: ____________ My child demonstrated the following difficulties immediately following birth: ____Breathing ____Unusual muscle tone ____Blue ____Reflux ____Jaundice ____Bleed/stroke ____Scars, bruises, head injury ____Other: _____________ ____Sucking/swallowing ____Other: _____________ Length of hospital stay: ____ NICU? (circle): Yes No Did you have any concerns at the time of discharge: (circle) Yes No If yes: Did your child require any medical equipment at the time of discharge (e.g., NG tube, apnea monitor, oxygen, shunt):
Please describe your child’s first months (e.g., colic, feeding, irritability, lethargy):
Health and Medical History Please describe your child’s general health (frequent colds, accidents or injuries, ear infections, bowel/bladder concerns):
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Have you ever consulted a medical specialist for specific health issues (i.e. neurologist, allergist, gastroenterologist)? (circle) Yes No If yes, please explain:
Please describe any special medical needs and/or precautions (e.g., cardiac, nutritional, respiratory, allergy):
Current medications: Does your child have seizures (circle): Yes
No
Age of first seizure and treatment: Age of last seizure and current treatment: Do you have any concerns about your child’s sleep habits?
Toileting History Please describe any toileting concerns you may have: At what age was your child toilet trained? Bowel: _____
Bladder: _____
Does your child suffer from (please circle): Constipation
Diarrhea
Nighttime: _____
Withholding
Vision History Has your child been evaluated by an ophthalmologist? (circle) Yes No If yes, date: ________ Results: Has your child been evaluated by an optometrist? (circle) Yes If yes, date: ________ Results: Does your child wear glasses? (circle): Yes No
No
If yes, circle: nearsighted
farsighted
Has your child been evaluated by a developmental optometrist (subspecialty)? (circle) Yes
No
If yes, date: ________ Results: Does your child demonstrate, or have a history of the following: (please check) ____Strabismus ____Eye(s) turning in/out ____Nystagmus ____Difficulty maintaining eye contact ____Rubbing his/her eyes ____Focus on rotating/twirling objects
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Hearing History Describe your child’s ear health history (e.g., frequent infections, drainage tubes, hearing test results):
Does your child use any assistive hearing devices? (circle) Yes If yes, please describe:
No
Social Emotional/Behavioral History What do you enjoy most about your child? What are his/her strengths?
What worries you most about your child?
How does your child calm himself/herself when upset:
Does your child have meltdowns or tantrums? (circle) Yes If yes, please describe:
How often do they occur?____________________
No
How long do the tantrums last? _______________
Does anything particular bring them on? How does your child do in group situations (school, playgroups, parties, family events, etc.)?
Does your child have any difficulty transitioning from one activity/setting to another? (circle) Yes If yes, please describe:
If your child attends school or daycare, are there concerns in that setting? ? (circle) Yes
No
If yes, please describe:
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No
Is completing homework an issue? (circle) Yes
No
If yes, please describe:
Is your child able to keep track of and/or need help organizing personal belongings? (circle) Yes
No
If yes, please describe:
Developmental History Do you have concerns about your child’s gross motor skills?
Do you have concerns about your child’s fine motor skills?
Does your child over/under react to any sensory information (touch, sounds, smells movements, etc.)? (circle) Yes If yes, please describe:
Do you have any concerns about your child’s attention? (circle) Yes No If yes, please describe: Do you have any speech and/or language concerns? (circle) Yes If yes, please describe:
No
How does your child communicate his/her wants or needs:
Do you have any concerns about your child’s eating? (circle) Yes No If yes, please describe:
Is there anything else that you feel would be helpful for us to know?
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No