Child Intake Packet

Date of evaluation *

Guardian/Caregiver Name *

Relationship to Child *

Is your child in good health? *

Yes

If not, please describe medical issues

Has your child been hospitalized? *

Yes

Does your child have a diagnosis? *

Yes

Vision *

Normal

Impaired

Wears Glasses

Contacts

Hearing *

Normal

Impaired

Hearing Aid

Cochlear Implant

Has your child suffered from ear infections? *

Yes

If so, how many and at what age?

Is Child *

Verbal

Non-Verbal

If child is non-verbal what is the primary mode of communication?

Does child have feeding difficulties? *

Yes

If so, please describe

Does child have difficulty swallowing (i.e. g-tube, ng-tube)? *

Yes

If so, please explain

Does child have allergies? *

Yes

List all medications child has taken in the past or is currently taking (dosage and type)

Does child employ specialized equipment at home? *

(i.e. standers, bathing/toilet chairs, wheelchairs, strollers, feeding chairs, adaptive equipment, feeding utensils, etc.)?

Has your child ever had speech/occupational/physical therapy in the past? *

Yes

What goals would you like your child to achieve during physical/speech/occupational therapy?

Did your child exhibit any of the following behaviors during the first few years of life to a noticeable degree?

Did not enjoy cuddling

Was not calmed by being held or stroked

Feeding difficulties

Did your child fail to gain weight or grow normally?

What ages did the following occur:

Fed self with spoon

Produced first word

Begin combining words

Taken off bottle

Taken off pacifier

Dressed and undressed self

Siblings: Name, Age, Gender

Is there a family history of developmental delays, speech problems, hearing loss, or learning problems?

What was the duration of the pregnancy?

Did you experience any of the following during pregnancy? *

Infections

Toxemia

Surgeries

Alcohol consumption

Smoking

Other

None

Did you take any medications during pregnancy? *

Yes

What type of delivery?

C-Section

Vaginal

Were there any complications during pregnancy?

What was your child’s birth weight?

Were there complications during delivery?

Select any that apply

Forceps

Cord around neck

Hemorrhage

RH incompatibility

Was your baby blue at birth?

Did your baby have breathing problems upon delivery? *

Yes

If yes, please describe

Was your baby in an incubator?

Yes

Was your baby in the NICU?

Yes

All children exhibit, to some degree, the kinds of behaviors listed below. Please check those that you believe your child exhibits to an excessive or exaggerated degree to compared to other children of similar ages.

What are your child’s favorite toys?

What types of play activities does your child enjoy most?

What toys/activities does your child dislike the most?

What activities do you enjoy doing with your child?

Does your child play with other children? *

School your child is attending *

What feedback have you received about your child’s school performance? *

Child Intake Packet

Patient Information

PHYSICIAN INFORMATION

HEALTH / MEDICAL HISTORY

DEVELOPMENTAL HISTORY

FAMILY HISTORY

BIRTH HISTORY

HOME/ PLAY/ SOCIAL BEHAVIORS

EDUCATIONAL HISTORY