OT Connection | New Patient Intake Form

OT
ST
PT

Patient Information

Date*

Referred by

Patient Name*

Date of Birth*

Age*

Please enter a number from 1 to 100.

Sex*

Parent's Name*

Home Phone*

Mobile Phone*

Email Address*

Address 1 Address 2 City State ZIP

Primary Concern/Diagnosis

Prescription from Doctor?

Yes
No

Therapy Evaluation Information

Primary Care Physician’s Name

Phone Number

Fax Number

Referring Physician’s Name

Phone Number

Fax Number

Insurance Information

Name of Insurance

ID #

Group #

Primary Insured

Date of Birth

SSN

Effective Date

Employer

For OT Evaluations

Does your child have difficulties with any of the following?

Self Care Skills:

Buttons
Clothing
Zippers

Sensory:

Textures
Body Awareness
Transitions

Fine Motor:

Scissors
Containers
Utensils

Pre-Writing/ Writing:

Coloring
Shapes
Letters

Gross Motor:

Strength
Coordination
Ball Skills

Social/Emotional:

Friendships
Emotional Regulation

For feeding concerns

Is your child on a limited diet?

Yes
No

Is your child a picky eater?

Yes
No

Does your child prefer certain temperatures?

Yes
No

Does your child only eat certain textures?

Yes
No

Current Weight

Weight lost?

Yes
No

General Development comments

A good sampling of foods that your child prefers
Some foods they will occasionally eat
Several foods they DO NOT LIKE
A drink (juice, milk or formula)
Containers they usually use (cup, bottle, bowl, spoon, etc.)

For ST Evaluations

How does your child communicate?

Single Word
Short phrases
gestures/signs
communication device

How much do you understand when they speak?(in %)

Intelligibility
articulation
sound errors

Do you have concerns with:

Social Skills/Pragmatics
interaction with peers/siblings

Any concerns mentioned from teachers or pediatrician regarding their Speech/Language:

What is the PRIMARY language spoken at home?

For PT Evaluations

Does your child have a medical diagnosis?

Down Syndrome
Austism
Other

If your child is under 12 months old, do they have any of the following diagnosis?

Torticollis
Plagiocephaly
Delayed Milestones
Other

If your child is over 12 months old, do they have any of the following diagnosis?

Low (soft) muscle tone
High(stiff) muscle tone
Gross motor delays
Toe walking
Fear of movement
Balance issues or fall frequently
pain w/ activity
issues w/ stairs, curbs ETC
Ride a bike, skateboard

Uses adaptive equipment (wheelchair, walker, orthotics?)

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