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New Patient Intake Form
New Patient Intake Form
OT
ST
PT
Patient Information
Date
*
Date Format: MM slash DD slash YYYY
Referred by
Patient Name
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Age
*
Please enter a number from
1
to
100
.
Sex
*
Female
Male
Parent's Name
*
Home Phone
*
Mobile Phone
*
Email Address
*
Address 1
Address 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Date Format: MM slash DD slash YYYY
SSN
Effective Date
Date Format: MM slash DD slash YYYY
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
Hot
Cold
Does your child only eat certain textures?
Yes
No
Smooth
Crunchy
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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