Patient History Form Occupational

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

Birth History

Developmental History

Education History

Behavior/Self Regulation

Medical History

Occupational History

● 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
● 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
● Dressing
● Feeding- self feeding, sensory aversions to food, oral motor control
● Bathing
● Grooming
● Social interactions
● Developmentally appropriate play

Environmental Factors,Habits and Routines