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Child's name Date of birth/Age Parent/guardian name(s) Address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Primary contact number Type - Type -HomeOfficeCell Phone Ext: Email address(s) Multiple email addresses may be separated by commas. Emails are only sent to cc and bcc addresses if a To email address is provided. Is there a language other than English spoken in the home? Yes No Primary contact number (2) Type - Type -HomeOfficeCell Phone Ext: How did you hear about the Occupational Therapy Clinic? Child lives with: Birth parent(s) Foster parent(s) Adoptive parent(s) Other… Enter other… Other children in the family (include name, age, grade and if there are any developmental concerns): Any cultural norms that you would like us to know about that might impact delivery of services for your child? Yes No Explain Enter other… Did mom have regular prenatal care? Yes No Did mom have any health problems during pregnancy? Please explain. Where was your child born? Delivery was: Pre term Term Post term Vaginal Cesarean section Were there any complications during delivery? Yes No Explain Enter other… Were there any problems with baby or mom in the hospital after birth? Yes No Explain Enter other… Birth weight Birth height Apgar scores Physician name Physician address Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Physician phone Specialists: Are immunizations up to date? Yes No Has your child had any accidents or injuries? Yes No If yes, please explain Enter other… Medical diagnosis As far as you know, has your child had difficulty with any of the following: Allergies Heart Eczema Stomach/bowel Anemia Feeding Asthma Vision Frequent fevers Hearing Ear infections Ear tubes Meningitis Seizures Sleeping Head injury Other, please explain Has your child had any accidents or injuries? Yes No If yes, please explain Enter other… Do you have any concerns about child’s: Questions Yes No Not sure Height Yes No Not sure Weight Yes No Not sure Head size Yes No Not sure Vision Yes No Not sure Hearing Yes No Not sure Movement Yes No Not sure Behavior Yes No Not sure Speech/language Yes No Not sure Eating Yes No Not sure Nutrition Yes No Not sure Sleeping Yes No Not sure Sensory processing Yes No Not sure Please give the approximate age that your child smiled Please give the approximate age that your child reached for objects Please give the approximate age that your child sat unsupported Please give the approximate age that your child crawled on hands and knees Please give the approximate age that your child walked alone Please indicate which words describe your child Affectionate Demanding Playful Overactive Calm Good disposition Shy Angry Stubborn Hard to comfort Curious Sad Likes people Confident Fearful Joyful Fearless Other Child's school and grade (if applicable) Child's favorite part of school Is your child having difficulty in school? Yes No If yes, please explain Enter other… Is your child receiving any help in school? Yes No If yes, please explain Enter other… Has your child ever had therapy services? Yes No If yes, please explain Enter other… What do you see as your child's strengths? What are your primary concerns for your child? *Please bring any OT evaluations, IFSP/IEPs, or other documents that would help evaluate plan for your child. What are some questions that you would like answered? Submit Leave this field blank
