Innovative Services NW Pediatric Therapy

Intake and History

Date:

Child’s Name: / Gender: / Male Female
Birthdate: / Is child… / Foster child Adopted *Please bring any custody paperwork, if needed
Child’s Race/Ethnicity: / Caucasian Hispanic/Latino American Indian or Alaska Native Asian
Black or African American Native Hawaiian or Other Pacific Islander Other
Native Language: / English Spanish Russian Other: / Interpreter Needed? / Yes No
Address: / City: / State: / Zip:
Primary Phone: / Secondary Phone:
Email: / Prefer contact by: / Phone Email
Mother/Guardian / Father/Guardian
Name: / DOB: / Name: / DOB:
SSN#: / Driver’s Lic: / SSN#: / Driver’s Lic:
Employer: / Employer:
Employer Address: / Employer Address:
Employer Phone: / Employer Phone:
Pediatrician NamePhone:
Public Health Nurse NamePhone:
CPS Caseworker Name & Phone:
Who referred your child to our Clinic?
Who does child live with? (please mark all that apply)
Mother: Biological Foster Step Adopted
Father: Biological Foster Step Adopted
Grandma Grandpa Other Adults (Please List):
Other Children in Home:
Name: / Age: / Name: / Age:
Name: / Age: / Name: / Age:
Name: / Age: / Name: / Age:
Billing Information:We need to verify medical insurance coverage at each appointment
Medical Coupons? / Patient ID Code/PIC number:
Insurance Company #1: / Policy Holder:
Claim Submission Address:
Phone: / Policy # / Group #: / ID#:
Insurance Company #2: / Policy Holder:
Claim Submission Address:
Phone: / Policy # / Group #: / ID#:
Therapy Requested: / Physical Occupational Speech Incontinence Aquatic Other:
For Physical Therapy evaluations, please have shorts to change into. For Feeding evaluations, please bring some of your typical food.
Why are you requesting these specific therapies?
Does your child have a diagnosis?
Concerns your doctor may have expressed about your child’s development?
Medications, vitamins, or supplements your child is currently taking:
Assistive Devices (glasses, wheelchair, splints, hearing aid, Cochlear Implant) and for how long?
Hospitalizations/Surgeries:
Chronic Illnesses (please include allergies and triggers):
Ear Infections (chronic): / Yes No / Tubes: / Yes No
DEVELOPMENTAL MILESTONES – How old was your child when he/she began the following skill? Leave blank if not yet learned
Rolling over: / Sitting without support:
Crawling: / Pull to a stand:
Walking Independently: / Making first sounds (coo, laugh):
Babbling (mama, dada, etc.): / Speaking first purposeful word: / Word was:
Finger feeding: / Spoon/fork feeding:
Open cup drinking: / Potty training:
ETHNIC BACKGROUND
Child’s country of origin: / How long has he/she live in US?
When/how did your child learn his/her current language(s)?
Language used most often in the home:
% child speak English in the home: / % child speaks native language in the home:
With whom does your child speak/interact in English?
Child’s language skills are stronger in: / English Native Language
Child’s language skills compared to his/her siblings:
PREGNANCY AND BIRTH HISTORY Cesarean Vaginal
Place of Birth: / Hospital:
Pregnancy Information/Concerns:
Was mother on any medications or exposed to any toxins (alcohol, tobacco, drugs) during the pregnancy?
No Yes Details:
Gestation: / Full-term Pre-Term # of weeks: / Weight: / Height:
Complications during or following the birth:
Length of stay for Mother: / Length of stay for child:
Did your child pass newborn tests? / Hearing: Yes No
FAMILY HISTORY
Significant events or lifestyle changes since your child’s birth (death in family, a move, divorce or marriage, abuse neglect, violence or a change in caregivers)
Your child’s strengths:
What does he/she enjoy?
Family members with similar conditions/concerns:
CAREGIVER/SCHOOL INFORMATION
Type of school your child attends and how often (daycare, preschool, school, N/A)
Location: / If in school, grade: / Does your child have an IFSP/IEP? / Yes No
Services received in school?
PREVIOUS EVALUATION/TREATMENTS – Has your child seen any of the following specialists
(please bring reports if available; or have provider fax prior to appointment)
Specialty / Where / When / Provider/Contact Info
Speech Therapist
Physical Therapist
Occupational Therapist
Chiropractor
Nutritionist
Neurologist
ENT
Audiologist
Vision Specialist
Cardiologist
Psychologist
Educational Therapist
Other:
Other information you would like us to know about your child:

Please fill out the specialty questions on the following pages

for the type(s) of therapy you are requesting.

If you are requesting PHYSICAL THERAPY,

please answer the following additional questions:

Physical Therapy Questions (For Physical Therapy evaluations please have shorts to change into)
Does your child have difficulty in head control, sitting, crawling, kneeling, standing and/or walking? / No Yes Details:
Does your child have difficulty with balance, coordination, falling, stumbling, and/or clumsy? / No Yes Details:
Describe your child’s gross motor play (throw/catch a ball, ride a bike/trike, 2-3 wheeled scooter, run, stairs, jump or hop, etc.):
Does your child complain of pain (feet, legs, back, etc.) and if so, is it correlated to a time of day or activity? When did it start? Does it impact daily life? / No Yes Details:
Does your child complain of being excessively tired or want to be carried all the time? / No Yes Details:
Do your child’s feet roll in and/or do they “lock out” their joints when standing? / No Yes Details:
Does it seem your child’s gross motor skills have regressed at any time during their development? / No Yes Details:

If you are requesting OCCUPATIONAL THERAPY,

please answer the following additional questions:

Occupational Therapy Questions (For Feeding evaluations, please bring some of your typical food.)
Does your child have a hard time manipulating toys, completing puzzles or using his/her hands together? / No Yes Details:
Does your child have a hard time eating like other children his/her age (i.e. utensils, cup, choking, eating a variety of textures)? / No Yes Details:
Does your child have a hard time falling asleep or staying asleep? / No Yes Details:
Does your child avoid/seek out touching certain textures, like sand, foods, mud or lotions or avoid/seek out getting messy? / No Yes Details:
Does your child seem clumsy, have poor balance, or bump into things more than peers? / No Yes Details:
Does your child prefer deep touch over light touch or vice versa (i.e. tickles, bear hugs, crashing)? / No Yes Details:
Is your child easily distracted by noise or very sensitive to common sounds (i.e. Vacuum, blender, loud voices, flushing toilet)? / No Yes Details:
Does your child seek out/avoid movement such as swings, slides, spinning and being upside down? / No Yes Details:
Does your child have temper tantrums in excess or have trouble calming? / No Yes Details:
Does your child become upset with changes in routine or schedules? / No Yes Details:
Please describe any other concerns regarding your child’s self-help, fine motor or sensory processing skills:

If you are requesting SPEECH THERAPY,

please answer the following additional questions:

Speech Therapy Questions (For Feeding evaluations, please bring some of your typical food.)
What percentage of the time do you understand your child’s speech?
Does your child follow single step directions? / No Yes Details:
Does your child follow multiple step directions? / No Yes Details:
Does your child respond to his/her name? / No Yes Details:
Is it difficult to gain or sustain your child’s attention? / No Yes Details:
Does your child use words to communicate? / No Yes Details:
Does your child combine words to form phrases or sentences? / No Yes Details:
Does your child have difficulty articulating sounds (speaking clearly)? / No Yes Details:
Does your child stutter (repeat words or parts of words when talking)? / No Yes Details:
Please describe any other concerns regarding your child’s speech and language skills: