154 S. Livingston Avenue ∙ Suite 204 ∙ Livingston ∙ NJ 07039 ∙ (973) 535-5010 ∙ www.pediatricpotentialsnj.com
New Patient Registration Form
Today’s Date: ______OT’s/PT’s Name: ______
Child’s first and last name: ______Nickname:______
Child’s Date of Birth: ______Age: ______Male/Female ______
Child’s Home Address: ______
City/State/Zip: ______School: ______
1. Parent’s Name: ______Occupation: ______
Phone: (H)______(W)______(Cell) ______
Email: ______
2. Parent’s Name: ______Occupation: ______
Phone: (H)______(W)______(Cell) ______
Email: ______
EMERGENCY NOTIFICATION: If you will be leaving your child during the session, please ensure your therapist has a way to reach you in the event of an unlikely emergency (Cell phone, beeper, and/or destination).
Are there any food allergies, seizures, medications or medical conditions which might affect your child’s ability to participate in testing or therapy activities? If yes, please describe and provide emergency information. (e.g. epi pen, seizure precautions, inhalers, latex allergies, profound carsickness, etc.)
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Name of Person(s) who may be accompanying your child to therapy if not a parent:
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Pediatrician Name: ______Phone: ______
Child’s school: ______Teacher: ______
School hours: ______Phone:______Grade:______
Who referred you to us? ______
Reason for the referral: ______
Sibling names and ages ______
Any Medical Problems? ______
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Are there any family crisis or recent difficulties that may be impacting on your child? Are there any significant events that have occurred in your child’s development that may have lingering affects (e.g. divorce, death, separation, new baby, move, serious illness, hospitalization, etc.)?
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Does your child require glasses, hearing aid, special shoe inserts, etc.? ______
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Is child receiving other therapies or tutorials? Please describe: ______
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Describe your impressions of your child’s problems. ______
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Has the problem changed since it was first noticed? ______
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Has your child received occupational or physical therapy services at any time? If yes, please
describe. When were services terminated? ______
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DEVELOPMENTAL MILESTONES
Describe any problems accompanying your pregnancy, delivery or neonatal period of time.
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Is your child adopted? No Yes If yes, does your child know about his heritage? Do you have
knowledge regarding your child’s birth history? ______
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Indicate approximate ages by which the following developmental milestones were reached. Describe any unusual aspects of your child’s development:
* Crawling ______* Sitting unsupported ______* Walking ______
* Talking (mama, papa) ______* Talking (short sentences) ______
* Toilet training ______
* First school experiences – Comments: ______
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* Present school experiences – Comments: ______
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Describe your child’s general behavior at home related to moods, independence, transitions, engagement, responsiveness, frustration, management and response to discipline, etc.
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Describe your child’s play time activities, including toys he/she prefers or avoids: ______
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SENSORY OBSERVATIONS
Does your child react adversely to touch, smell, movement, heights?
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Does your child have any difficulty with any of the following? If so, describe briefly.
* tolerating noises No Yes Sometimes______
* tolerating light No Yes Sometimes ______
* sleeping No Yes Sometimes ______
* tolerating clothing No Yes Sometimes ______
* baths (including hair washing) No Yes Sometimes ______
* swimming -- describe level ______
* stairs No Yes Sometimes ______
* bike riding -- describe the highest level of riding toy achieved ______
* playing with children the same age No Yes Sometimes ______
* dealing with crowds No Yes Sometimes______
* following several instructions No Yes Sometimes ______
* trying or learning new games or activities No Yes Sometimes ______
* novel foods No Yes Sometimes ______
* novel experiences No Yes Sometimes ______
* separation from parents/siblings No Yes Sometimes ______
* tantrums No Yes Sometimes ______
* transitions No Yes Sometimes ______
* other ______
Describe what you hope your child will accomplish in an occupational or physical therapy program.
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Please add any comments or descriptions which will help us to better understand your child and your concerns for your child.
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Prepared by SN Pediatric Potentials, Inc. 1/2013