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Home
Therapists
Parent Information
Services
- Speech Therapy
- Occupational Therapy
  - OT Evaluation and Treatment
Get Started
- Insurance and Payment Options
- New Patient Forms
Photos
Contact Us
- Arlington
- DeSoto
- Garland
- Irving
- Mesquite
- North Richland Hills
- Richardson
- Royse City
- Wylie

Home
Therapists
Parent Information
Services
- Speech Therapy
- Occupational Therapy
  - OT Evaluation and Treatment
Get Started
- Insurance and Payment Options
- New Patient Forms
Photos
Contact Us
- Arlington
- DeSoto
- Garland
- Irving
- Mesquite
- North Richland Hills
- Richardson
- Royse City
- Wylie

Menu

Home
Therapists
Parent Information
Services
- Speech Therapy
- Occupational Therapy
  - OT Evaluation and Treatment
Get Started
- Insurance and Payment Options
- New Patient Forms
Photos
Contact Us
- Arlington
- DeSoto
- Garland
- Irving
- Mesquite
- North Richland Hills
- Richardson
- Royse City
- Wylie

Patient History Form Occupational

Please fill in the following information to the best of your ability.

Clinic Location *

Full Name *

Date of Birth *

Age/Sex *

First

Last

Address *

Address Line 1

City

State

Zip Code

Telephone *

Person Completing This Form *

Relationship to Client *

1. Parent's Name / Age *

First

Last

1. Parent Address *

Address Line 1

City

State

Zip Code

2. Parent 2's Name / Age ( If applicable)

First

Last

2. Parent 2's Address

Address Line 1

City

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 *
Name | Age | Sex | Grade in School | General Health ( Hit enter for new line)

List all children in the family from oldest to youngest *

Who referred you for the evaluation *

Child’s pediatrician or family doctor *

Address *

Other doctor(s) treating the child *

Is your child currently or have they previously received other therapy services (i.e. early childhood intervention or school-based therapy? *

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? *

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: *

First

Last

Crawling / Standing unsupported *

First

Last

Walking / Eating solid foods *

First

Last

Self-feeding : finger - feeding / using spoon / fork *

First

Last

Self-dressing: lifting arms/stepping in to pants / Dressing self independently *

First

Last

Bladder/bowel control: Tells you when needs to go / Sits on toilet independently *

First

Last

Manages clothing / wipes self *

First

Last

Do you feel that your child was late or had difficulty in the development of these skills? *

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? *

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 *

Contact Us

(972) 454-9309
Info@SynapticPediatricTherapies.com

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Ft Worth Area with multiple locations

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Copyright © 2022 Synaptic Pediatric Therapies, LLC. All rights reserved.

Digital Transformation by Digital Marksmen

Menu

Home
Therapists
Parent Information
Services
- Speech Therapy
- Occupational Therapy
  - OT Evaluation and Treatment
Get Started
- Insurance and Payment Options
- New Patient Forms
Photos
Contact Us
- Arlington
- DeSoto
- Garland
- Irving
- Mesquite
- North Richland Hills
- Richardson
- Royse City
- Wylie

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