Patient’s Name (required)

Today’s Date (required)

Mailing Address

Date of Birth (required)

Grade

Home Phone

School

Cell Phone

Siblings

Email

What are your primary concerns and reason for referral? Please consider all areas of development that apply to your child, i.e. academics, self care skills, social relationships, sensory processing, fine and gross motor skills, and play skills, speech and language development.

What are your child’s favorite things to do and play with (i.e. hobbies, sports, toys)?

Has your child received a diagnosis?
YesNo

Please list any diagnosis.

Please list any evaluations your child has had, including place and date. Please attach any relevant assessments.



Attach relevant assessments

Please indicate name and address, only if your child has ever been seen by any of the following.

Psychologist


Neurologist


Physical Therapist


Speech Therapist


Occupational Therapist


Audiologist

Please describe your child’s birth history. List any complications during pregnancy, birth, and infancy.


Is your child adopted?
YesNo
If yes, please describe circumstances surrounding the adoption.

Looking back at the first two years of your child’s life, what type of baby was he/she (i.e.
feeding, sleeping, activity level, temperament)?


Please answer the following:
Breastfed
YesNo
Bottle Fed
YesNo
Specific Health Problems
YesNo
Thumb sucker/pacifier (to what age)
YesNo
Feeding problems
YesNo
Sleeping problems
YesNo
Colic or fussy baby
YesNo
Prefers certain positions
YesNo
Dislikes stomach
YesNo
Dislikes back
YesNo
Able to self sooth
YesNo
Mouthed toys
YesNo
Enjoys bouncing
YesNo
Calmed by car rides/infant swing
YesNo
Becomes upset by car rides/swing
YesNo
Toe walker (until what age)
YesNo
Feeding/swallowing difficulties
YesNo

Comments regarding previous answers:

Did your child have any illnesses such as ear infections, tubes, respiratory problems, fevers, frequent colds? Please list.

Has your child had any difficulties with diarrhea, constipation, vomiting, headaches, or stomach aches? Please describe.

Does your child have any allergies? Please list.

Does your child currently take any medications? Please list and indicate for what conditions.

Please give approximate ages if remembered, or comment on anything unusual.
Rolled Over

Walked

First words

Sat alone

Chewed solid food

First sentence

Crawled

Drank from a cup

How long did your child crawl?

Can your child go up and down stairs safely? How?

Please describe if your child had any difficulties achieving motor milestones.

Please describe any developmental challenges your child has faced or continues to face.

Do you have any concerns about your child’s vision?
YesNo

If is Yes, what are they?

Has he/she had a vision exam?
YesNo

If is Yes, when?

Does your child wear glasses?
YesNo

Does your child do any of the following:

Close one eye or “wink”
YesNo

Trip/Fall frequently
YesNo

Tilt head to one side
YesNo

Have difficulty reading
YesNo

Complain of headaches
YesNo

Avoid eye contact
YesNo

Do you have any concerns about your child’s hearing? Please explain.

Has your child had a hearing test or screening? What were the results?

Does your child do any of the following:

Cover his/her ears
YesNo

Confuses similar sounding words
YesNo

Not respond to call
YesNo

Gets easily distracted
YesNo

Avoid/ “fall apart” in noisy environments
YesNo

How would you describe your child’s speech development (normal, delayed, advanced)?

Can you and others understand what your child is saying?

How would you describe your child’s speech and development?

When were your child’s first words?

First sentence?

How does your child communicate (gestures, babbling, words, sentences)?

Has your child had any problems learning to read? Write?

Does your child get frustrated by his/her difficulty or inability to communicate?

Are the parents bilingual?
YesNo

What language is spoken at home?

What language does your child use most?

Does your child stutter? Describe

How is your child’s behavior in school?

Describe any speech or language concerns or problems

Do you have any concerns about your child’s fine motor? Please explain.

Does your child have a hand preference (right, left, none)?

Please check all that apply to your child:
Holds a pencil/crayon well
YesNo

Able to manipulate objects
YesNo

Enjoys coloring
YesNo

Uses both hands together
YesNo

Able to snip with scissors
YesNo

Writes numbers and letters
YesNo

Able to cut paper
YesNo

Primarily scribbles
YesNo

Draws a picture
YesNo

Draws a person
YesNo

Pick up small objects
YesNo

Please describe your child’s mealtime behavior and level of independence (what does he/she eat and/or avoid, what is your child’s typical appetite, and behavior)

Please select all that apply to your child
Eats with fingers
YesNo

Uses a spoon
YesNo

Uses a fork
YesNo

Drinks from open cup
YesNo

Drinks from Sippy cup
YesNo

Drinks from Bottle
YesNo

How many/day?

Total number of ounces/day

Please describe how your child gets dressed (types of clothes, cooperation, level of independence, behavior).

Manages
Snap buttonsButtonsZippersTies shoes

Toilet trained?

Please describe your child’s sleep habits. Include bedtime routines, hard to fall asleep, difficult to wake, amount of sleep, amount of naps.

Can your child make transitions between places or people? Please describe any routine needed to assist in transitions (i.e. objects, need for advanced warning, timers).

Does your child:

Enjoy hugs and kisses
YesNo

Enjoy interactive play with others
YesNo

Attempt to comfort others
YesNo

Display wide variety of emotions
YesNo

Prefer to play alone
YesNo

Have frequent tempers
YesNo

If is yes, how many a day?

Engage in eye contact during communication?
YesNoSometimes

How long do they last?

Is he/she able to calm themselves?
YesNo

Please describe your child’s typical play skills. Include information such as ages of other children your child tends to play with, types of activities, ability to play with or near another child, ability to share or take turns

Describe your child’s behavior on outings such as shopping, birthday parties, restaurants, and family vacations.

Please check all that apply to your child:

My child is overly sensitive to sensory experiences more so than other children his/her age.
AuditoryTactileVisualMovementTasteSmell

My child does not react to sensory experiences as readily as other children his/her age.
AuditoryTactileVisualMovementTasteSmell

My child seeks out sensory experiences more so than other children his/her age.
AuditoryTactileVisualMovementTasteSmell

My child has difficulty differentiating sensory experiences (i.e. confuses sounds, cannot find objects in a drawer or bag without looking, bumps into things, etc.)

Please describe

My child has trouble learning new movements.
YesNo

My child tends to be clumsy and has balance and coordination problems.
YesNo

Does your child receive special education services? Please include frequency of each (i.e. resources, speech therapy, OT, PT).

Is your child able to move around the school independently, tolerate noises in the cafeteria, and attend assemblies, specials, and field trips?

What do you see as your child’s strengths?

What are your goals for your child?

Please feel free to share any additional information you feel would be helpful.