New Patient History Intake Form
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New Patient History Intake
Assigned to: _________________________ ( )OT ( )PT ( )SLP
Intake Date: _______________
How did you hear about Tiny Tots Therapy Inc.? _______________________________________________________
Today’s Date: _______________________
Last Name: _________________________ First Name: _________________________ DOB: ___/___/___ Sex: M / F
Home Address: ______________________ City: _________________State: _____ Zip: _______ Phone: ____________
Mother’s Last/Frist Name: ____________________________ Father’s Last/First Name: __________________________
Marital Status: ( ) Single ( ) Married ( ) Other
Can we leave messages regarding appointments on your home and mobile phones? Yes / No
Employer Name: _________________________________Work Phone: _______________Cell Phone: ______________
Work Address: ______________________ City: _________________State: _____ Zip: _______ Phone: _____________
I
nsurance Information
Insurance Company: __________________________________________________ Insurance #: ______________________________________
Member Name: _____________________________________________________ SS #: _____________________________________________
Physician’s Information
Physician’s Last Name: ____________________________________________ Physician’s First Name: ___________________________________
City: __________________________State: ____________ Phone: __________________________ Do you have a prescription? Yes / No
Reason For Today’s Visit
Diagnosis: ______________________________
Has your child ever received therapy before? Y / N when?________where?_________type of services?_______________________________
Is your child ambulatory (can walk) or not? Y / N
Is your child verbal or non-verbal? ______________________________________________
Does your child use any assistive devices? Y / N If YES, please describe: _________________________________________________________
What areas are most di cult at Home?__________________________________________At School? _________________________________
Patient’s Medical History
( )Measles ( )Mumps ( ) Pneumonia ( )Chicken Pox ( )Bronchitis ( )BPD ( )Re ux ( )Head Injuries ( )Tonsilitis
( ) Ear Infections If YES: Frequency? __________ Last Ear Infections: __________ Treatment Method: _________________________________
( ) Sleep Concerns If YES: What are your concerns? __________________________________________________________________________
Please list any allergies: _________________________________________________________________________________________________
Please list any hospitalizations, inlcuding dates: _____________________________________________________________________________
Surgeries Performed: ( ) G-Tube ( )Ear Tubes, If YES, still in place? Y / N
( )Heart Repair ( )Trach ( ) Shunt ( )Tonsillectomy ( ) Appendectomy ( ) Other: _________________________________________________
Tests Performed: ( )MRI ( )CT Scan ( )Genetic Testing ( )X-rays ( )Other: _______________________________________________________
Please list any current medications: _______________________________________________________________________________________
Does your child have seizures? Yes / No If YES: Frequency? __________ Description: ______________________________________________
Does your child have a special diet? Yes / No (If YES, please provide a copy)
Please list any family history (i.e. medical conditions): ________________________________________________________________________
Prenatal & Birth History
Complications During Pregnancy:
( ) Diabetes ( ) Measles ( ) Toxemia ( ) Premature Labor ( ) Strep ( ) Respiratory ( ) Other: ____________________
Complications During Delivery:
( ) Cesarean Section ( ) Emergency ( ) Forceps ( ) Vacuum ( ) Other: ______________________________________
Child’s Condition After Birth:
( ) Premature If YES: Gestational Age: _____ Apgars ___ NICU ___ Jaundice ___ Heart Problems ___ Poor Suck ___Other ___
( ) Ventilator If YES: How Long? __________ ( ) Small For Gestational Age ( ) Large For Gestational Age
Known Diagnosis (e.g. Down’s Syndrome): _____________________________________________________________
Other Medical Complications: _______________________________________________________________________
Child’s Developmental History
Please list the approximate age the patient accomplished the following: Lift head while on tummy _____ Rolled over _____
Sat w/o support _____ Crawled _____ Stood alone _____ Walked alone _____ Dress self _____ Button/zip clothes _____
Started solid food _____ Used fork _____ Held cup _____ Drank from sippy cup _____ Drank from open cup _____
Bowel control _____ Dry during day _____ Night _____ Does your child have any bladder or bowel di culties? Y / N
Please describe bowel di culties: _____________________________________________________________________
Hand Preference: ( )Left ( )Right
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