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Therapists
Parent Information
Developmental Milestones
Occupational Milestones
Speech Milestone
Speech Resources
Occupational Resources
Diagnosis/Deficits Commonly Addressed
Areas Of Occupation
Services
Speech Therapy
Speech Sound Disorders
Fluency Disorder
Language Disorders
Pragmatic Language Disorder
Cognitive-Communication Disorders
Childhood Apraxia of Speech
Occupational Therapy
OT Evaluation and Treatment
Get Started
Insurance and Payment Options
New Patient forms
Careers
Photos
Contact Us
Arlington
DeSoto
Garland
Irving
Mesquite
North Richland Hills
Richardson
Royse City
Wylie
COVID NOTICE
Schedule Today
Patient History Form Occupational
Please fill in the following information to the best of your ability.
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Clinic Location
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Select
Arlington
DeSoto
Garland
Irving
Mesquite
North Richland Hills
Richardson
Royse City
Wylie
Full Name
*
Date of Birth
*
Age/Sex
*
First
Last
Address
*
Address Line 1
City
State / Province / Region *
Alabama
Alaska
Arizona
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California
Colorado
Connecticut
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District of Columbia
Florida
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Iowa
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Louisiana
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New York
North Carolina
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Ohio
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Pennsylvania
Rhode Island
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South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Telephone
*
Person Completing This Form
*
Relationship to Client
*
1. Parent's Name / Age
*
First
Last
1. Parent Address
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Address Line 1
City
State / Province / Region *
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
State
Zip Code
2. Parent 2's Name / Age ( If applicable)
First
Last
2. Parent 2's Address
Address Line 1
City
State / Province / Region
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
State
Zip Code
Parent’s Occupation
Has the child or any member of the family been tested positive for COVID-19?
*
Yes
No
Who lives in the home with the child?
*
List all children in the family from oldest to youngest
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Name | Age | Sex | Grade in School | General Health ( Hit enter for new line)
List all children in the family from oldest to youngest
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Who referred you for the evaluation
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Child’s pediatrician or family doctor
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Address
*
Other doctor(s) treating the child
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Is your child currently or have they previously received other therapy services (i.e. early childhood intervention or school-based therapy?
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Yes
No
If yes, please list location and areas of need being addressed
Birth History
Pregnancy
*
Normal
Abnormal / Complications
Explain
Length of Pregnancy
*
Premature
*
Yes
No
Birth weight
*
Delivery was
*
Vagical
C-Section
Emergency C-Section
List any complications at delivery?
*
Did the child experience any complications immediately following birth?
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Yes
No
Explain
Developmental History
In early childhood, did child have any feeding/swallowing problems (such as poor control of sucking, food allergies, and/or digestive upsets)?
*
Yes
No
If yes, please describe
Please list ages at which your child met the following developmental milestones:
Rolling / Sitting unsupported:
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First
Last
Crawling / Standing unsupported
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First
Last
Walking / Eating solid foods
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First
Last
Self-feeding : finger - feeding / using spoon / fork
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First
Last
Self-dressing: lifting arms/stepping in to pants / Dressing self independently
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First
Last
Bladder/bowel control: Tells you when needs to go / Sits on toilet independently
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First
Last
Manages clothing / wipes self
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First
Last
Do you feel that your child was late or had difficulty in the development of these skills?
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Yes
No
Explain
Education History
Current School
*
Grade
Describe performance in school (please note strong and weak areas)
*
Does your child currently receive special education or accommodations under 504? (such as speech, occupational, or physical therapy, resource or inclusion time, special education classroom)?
*
Yes
No
If yes, please describe
Behavior/Self Regulation
Are you concerned with your child’s social skills?
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Yes
No
If yes, please explain:
Does the child prefer to play alone?
*
Yes
No
Does the child have a close friend?
*
Yes
No
Does your child have difficulty staying focused?
*
Yes
No
If yes, please explain
Describe how your child interacts with his/her peers
*
How does your child respond to discipline? What is/is not effective?
*
What are your behavioral concerns?
*
Does your child appear to have difficulty regulating their emotions? If so, please describe:
*
Do you have any concerns regarding sensory processing including seeking and/or sensitivity to sensory input? If yes, please describe:
*
Medical History
Has your child been diagnosed by a physician with any medical diagnosis or conditions?
*
Yes
No
if yes, please describe
Is the child currently taking any medications?
*
Yes
No
if yes, please describe
Does your child have any allergies (food, medicine, or seasonable such as hay fever, etc.)?
*
Yes
No
if yes, please describe
Has hearing been tested?
*
Yes
No
If yes, when
Results
Has the child ever had ear (PE) tubes inserted?
*
Yes
No
If yes, when?
Does your child currently have or have they ever had a cerebral shunt?
*
Yes
No
If yes, please describe
Does your child wear eyeglasses or have they had any difficulty with their eyes/vision?
*
Yes
No
if yes, please describe
Has your child seen a specialist for any reason?
*
Yes
No
If yes, please explain
Occupational History
Current areas of concern (Please check all that apply and include specific concerns):
*
Fine Motor Skills
Fine Motor Skills
This could include:
● Object manipulation & use of tools (picking up and playing with toys and objects of various sizes; using tools for School including scissors, glue, writing utensils, etc...
● Strength
● Coordination/Dexterity
Gross Motor Skills
Gross Motor Skills
This could include:
● Accessing all environments including home, school, and community (i.e playground) with or without the use of an assistive device (such as walker or wheelchair)
● Crawling, walking, running
● Strength, balance, endurance
Self-Care
Self-Care
This could include:
● Dressing
● Feeding- self feeding, sensory aversions to food, oral motor control
● Bathing
● Grooming
Play
Play
This could include:
● Social interactions
● Developmentally appropriate play
5
Sensory Processing/Regulation
5
Emotional/Behavioral Concerns
Environmental Factors,Habits and Routines
Is there a language other than English spoken in the home?
*
Yes
No
If yes, which language
Does the child speak the language?
*
Yes
No
Does the child understand the language?
*
Yes
No
Which language does the child prefer to speak at home?
*
What does your child enjoy and how do they like to play?
*
What are your child’s typical habits and routines?
*
Patient or Parent / Guardian Signature (Printed name will count as Signature)
*
Relationship to Patient
*
Date
*
Submit
Menu
Therapists
Parent Information
Developmental Milestones
Occupational Milestones
Speech Milestone
Speech Resources
Occupational Resources
Diagnosis/Deficits Commonly Addressed
Areas Of Occupation
Services
Speech Therapy
Speech Sound Disorders
Fluency Disorder
Language Disorders
Pragmatic Language Disorder
Cognitive-Communication Disorders
Childhood Apraxia of Speech
Occupational Therapy
OT Evaluation and Treatment
Get Started
Insurance and Payment Options
New Patient forms
Careers
Photos
Contact Us
Arlington
DeSoto
Garland
Irving
Mesquite
North Richland Hills
Richardson
Royse City
Wylie
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