Please enable JavaScript in your browser to complete this form.1General Information2Reason for Today's Evaluation3Birth History4Developmental History5Nutritional History6Self-Care7Sleep Patterns8Medical History9Behavioral History10Educational HistoryToday's Date: *Child's Name: *FirstLastGender: *MaleFemaleDate of Birth: *Address: *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeParent Name: *FirstLastEmail: *Occupation:Parent Name: FirstLastEmail: Occupation: Primary language spoken at home:Names and ages of those living in the home:Referred by: *Pediatrician Name: *FirstLastPediatrician Phone Number:NextWhat are your primary concerns with your child at this time?When did you first notice these concerns and how did they become apparent to you?Please describe the reasons for seeking occupational therapy services at this time.Has your child received previous evaluations or interventions?YesNoIf yes, what kind, where and when?Is your child currently receiving other interventions or therapies?YesNoPsychotherapyPhysical TherapyOccupational TherapySpeech TherapyVision TherapyNutritional TherapyBehavioral TherapyOther:If yes, please list duration, location, and frequency.Does your child attend daycare, school or other programs?YesNoIf yes, where and when?If no, what is his/her daily schedule? Who is home with him/her?PreviousNextWere there any complications during pregnancy?YesNo(e.g. gestational diabets, preecplamsia, premature labor)If yes, please explain.Did mother take any medication during pregnancy?YesNoIf yes, what were they and why were they taken?Where was your child born?HospitalBirthing CenterHomeIf hospital or birthing center, please name the facility:Type of Delivery:VaginalCesareanTerm(Weeks)Birth Weight and Length:Mother's Age:Father's Age:# Days in Hospital:Were there any complications during birth?YesNoPremature birthJaundiceFeeding difficulty Emergency cesareanBreathing difficulty TransfusionSuctionTube FedIncubationForcepsCongenital defectsLow APGAROther Complications:(Please explain)Was your child in the NICU?YesNoIf yes, why and for how long?The following is a list of infant behaviors. Please check all that apply to your child as an infant:Cried a lot, fussy, irritableFloppy when heldQuiet or passiveGood sleep patternsResisted being heldAlertVery activeDrooled excessivelyGood, non-demandingTense when heldLiked being heldIrregular sleep patternsPreviousNextHow old was your child when he/she first:Rolled over:Sat independently:Crawled:Pulled to stand:Walked independently: Talked (single word):Spoke in sentences:PreviousNextBreast fedHow long?Any difficulties?Bottle fedHow long?Any difficulties?Has your child experienced any of the following?ColicFood allergiesSucking/latching problemsGrowth/nutritional problemsGERD/refluxother feeding problemsAge of transition to:Cereal:Solids:Finger foods:Table foods:Did your child experience any difficulty during these transitions?YesNoIf yes, please explain.Does your child use utensils?YesNoDoes your child currently experience any difficulties with feeding?Spitting upFussy eaterRefusal to eatOvereatingOther feeding problemsDoes your child experience difficulties with:Biting foodChewing foodMoving food around in the mouthSwallowing foodOther:If yes, please explain. PreviousNextDoes your child participate in getting dressed?YesNoDoes your child require assistance to:Put on / take off their shirt Put on / take off shoesButton or unbuttonUse velcro fastenersPull up / take off pantsTie shoesPull a zipper up or downPut on / take off socksFasten snaps / pull apart snapsUse a buckle Please describe:Is your child toilet trained?YesNo Do toileting accidents occur? YesNoIf yes, what time of day do the accidents typically occur?Does your child experience difficulty participating in any of the following activities?Brushing teethTaking a bathBrushing hairTrimming nailsTaking a showerGetting his / her face wetPlease describe: PreviousNextDoes your child experience any difficulty falling asleep?YesNoWhat time does your child go to bed for the night?What time does your child wake up in the morning?Does your child sleep through the night?YesNoIf no, how many times does he / she wake up during a typical night?Does your child nap during the day?YesNoIf yes, how many naps per day?What time does your child go down for a nap?Duration of nap?PreviousNextDoes your child have any medical diagnoses?YesNoIf yes, please explain:Has your child had any of the following? Please check all that apply.Frequent colds / respiratory illnessLung condition / respiratory disorder Heart conditionHormonal problemJoin or bone problemVisual disorder / problemSeizures or convulsionsFailure to thriveDiarrhea problemsHead injuries / concussionsFrequenters strep throat / sore throatFrequenters ear infections (tubes?)Anemia / blood disorderUrinary problems / infectionsFractured bonesEye infectionStomach disordersFeeding problemsHearing loss / ear disorderIngestions of toxins, poisons or foreign objectsBirth defect / genetic disorderAllergies or asthmaKidney / renal disorderMuscle disorder / problem Skin disorder / problem Neurological disorderVomiting / digestion problemsConstipationSignificant accidents / traumaHas your child had any major medical procedures / surgeries?YesNo If yes, please provide the date and results given.Has your child taken any medication for longer than 30 days / is your child taking any maintenance medications?(Please list medication, time of day it is taken and what it is treating)Has your child had any major medical illnesses(e.g. chickenpox, hand, foot and mouth, croup, etc.)Has your child received all of the vaccinations recommended by your pediatrician?YesNo If no, please explain.Has your child been hospitalized? (Please list date and reason)Has your child had a hearing test?YesNoIf yes, please list date of test and results. Has your child had an eye exam?YesNo If yes, please list date and test results.Does your child wear glasses?YesNo PreviousNextDoes your child experience difficulty with any of the following:Transitioning away from a preferred activityDealing with unexpected change in routineTransitioning from one caregiver to anotherTransitioning from one activity to anotherTransitioning from one environment to another If yes, what is his / her typical response?Does your child become frustrated easily?YesNoDoes your child have friends?YesNoDoes your child play with other children?YesNoWhat does your child enjoy doing?Does your child use toys the same way each time play occurs or is his / her play routine constantly changing and evolving? Please describe. PreviousNextPlease complete the following only if your child attends preschool, kindergarten or elementary school. Name of current school:School address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSchool phone:Teacher's name:FirstLastEmailDoes your child have an individualized education plan? (IEP)YesNoIf yes, what service(s) does he / she receive?If your child is in private school, does he / she receive any Special Education Services?YesNoIf yes, what service(s) does he / she receive?Has your child's teacher expressed any concerns with you regarding your child?YesNoIf yes, please describe.CommentSubmit
