Childs Name* First Middle Last Nickname Birth Date* Month Day YearAgeAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Select a State ZIP Code Lives WithGuardian 1* First Last Address* Address same as child Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Select a State ZIP Code Home PhoneWork PhoneCell PhoneEmail* Guardian 2 First Last Address Address Same As Child Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneWork PhoneCell PhoneEmail Billing Email Address (invoices will be sent via email to this address)* SIBLING INFORMATIONName First Last AgeRelated DifficultyName First Last AgeRelated DifficultyName First Last AgeRelated DifficultyOther individuals living in the homeOther Language spoken in the homeBIRTH HISTORYMedications Taken during pregnancy or laborBirthplaceDoctorBirth WeightLength of LaborLabor Normal Induced C-SectionLength of Hospital StayList any special care or precautions taken (bed rest, oxygen, jaundice, etc.)MEDICAL HISTORYPediatricianPhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Select a State ZIP Code Date of last physical Month Day YearResultsDate of last Hearing Screening Month Day YearResultsDate of last Vision Screening Month Day YearResultsHas your child ever been given a medical diagnosis? If so, what?Allergies (please note reactions to allergies if applicable)Current Medications:Please Check all that apply: Frequent colds Frequent Respiratory infections Frequent ear infections Hearing Loss Chicken Pox Excessively high fevers Mono Spinal Meningitis Epilepsy Cerebral Palsy Traumatic brain damage Seizures OtherOther DescriptionPlease provide any information pertinent to checked itemsHospitalizationsOther Professionals Working With Your Child Name Phone Name Phone Name PhoneMotor DevelopmentNote age of:Sat upCrawlWalkWalking up/down stairsJump ( 2 foot )Potty TrainedRiding a bikeCheck if appropriate: Trips or falls easily Fear of heights Afraid of climbing Difficulty grasping items ClumsySELF CAREPlease check what your child CAN do: Snaps buttons Zippers Put on socks/shoes Velcro straps Pull up/down pants Remove jackets Pull on shirt Tie shoesPlease describe concerns related to self-care (i.e., dressing, using the toilet, bathing)Has your child had an occupational therapy evaluation in the past? Yes NoPlease note place and findings:Has your child received occupational therapy services in the past? Yes NoPlease note place and findings:Has your child had an occupational therapy evaluation in the past? (If so, what were the results?)Has your child received occupational therapy services in the past? (If so, note when and for what reason)FEEDING DEVELOPMENTNote Age Of:Breast-fedDrinking from a bottleDrinking from a cupUsing UtensilsEating Table FoodDoes your child have difficulties sucking, swallowing, chewing, drinking from a cup, drinking fron a straw, eating different textures? (Explain)Strong food preferences?Avoids or dislikes certain foodsFood AllergiesSPEECH AND LANGUAGE DEVELOPMENTNote Age Of:Babbling (bababa)Jargon (linking babbling together)First WordsCombining wordsIs the child aware of difficulties he/she may be experiencing?PSYCHOLOGICAL AND NEUROLOGICAL DEVELOPMENTHas your child had a psychological assessment? (If yes, please note reason, date and place and a brief summary)Has your child had a neurological evaluation? (If yes, please note reason, date and place and a brief summary)Please check all that apply: Nervous Hyperactive Sleepless Wets Bed Nightmares Sad Withdrawn Shy Easily Upset Destructive Aggressive Temper Tantrum Head Banging Swaying Tics Anxiety Sensitive to sound in the enviroment Underreactive to Sound Short attention span Sensitive to being touched Underreactive to Being Touched Fearful of new situations, people, enviroment Preservative behaviors ( doing something over and over )EDUCATIONAL DEVELOPMENTCurrent GradeTeacherSchoolPrevious Schools AttendedSpecific concerns regarding schoolSpecial services received at schoolSpecial services received outside of schoolChild's attitude toward school and learning new thingsWhat are you hoping to gain/explore from evaluation or therapy?Please note any concerns or related issues not covered in this case historyINSURANCE INFORMATIONWe will not bill your insurance company directly, but we can put this information on your bill to make the process easier for you.Do you plan on filing for insurance reimbursement? Yes NoName of Insurance CompanyName of InsuredPolicy or authorization numberFINAL INFORMATIONIt may be helpful to keep a 2 day log of foods your child eats and bring this information to your first appointment.Who were you referred by?Preferred therapy days:Preferred therapy times:NumberNameThis field is for validation purposes and should be left unchanged.
