Fillable New Patient History Intake Form (Page 2 of 3) in pdf

Child’s Hearing/Vision History

Has your child ever had a vision test? Y / N If YES, last date performed: ______ Results: ________________Does your child wear glasses? Y / N

Has your child ever had a hearing test? Y / N If YES, last date performed: _________ Results: ____________________

Does your child wear a hearing aide? Y / N If YES, please indicate ( )Left ( )Right

Child’s Speech History

List the age the child accomplished the following:

Babble _______ Said rst words ______ Combined words ______ Follow simple directions _____

Does your child respond when his/her name is called? Y / N

Approximately how many words does your child have? ___________________

How does your child tell what he/she wants? _______________________________________________________________________________

Check any areas of concern regarding speech and language: ( )Length of statements ( )Ability to produce sound correctly

( )Ability to nd the right word ( ) Fluency of speech ( )Quality of voice ( )Ability to stay on topic ( )Ability to sustain attention

( )Ability to establish peer relationships ( )Frustration with speech di culties

When did you rst notice di culties with your child speech? __________________________________________________________________

Is there any family history of speech and/or language di culties you would like us to know about? __________________________________

How does your child communicate with you? ( ) Verbal ( )Assistive Device ( )Gestured ( )Other ____________________________________

Child’s Sensory History

Do your child’s hands, feet, and/or tummy seem overly sensitive to touch? Y / N

Does your child seen distractable or overactive? Y / N If YES, please describe: _________________________________

Does your child tolerate tooth brushing? Y / N

Does your child hesitate on uneven surfaces? Y / N

Does your child have di culty positioning him/herself in a chair? Y / N

Does your child seem generally weak? Y / N

Does your child push/bump into other children? Y / N

Does your child avoid getting hands messy? Y / N

Does your child seem hesitant on stairs? Y / N

Does your child spin, rock, or hit self when distressed? Y / N

Does your child have di culty participating in sports with other children? Y / N

Does your child have a fear of using playground equipment (see-saw, swing)? Y / N

Does your child demand only to wear certain clothes all the time? Y / N

Does your child close one eye or tip head back when looking at something? Y / N

Is there a sensory diet in place? Y / N If YES, please describe the sensory diet on back or provide a copy.

Please list any behavioral issues: __________________________________________________________________________________________

Any behavioral strategies being used? _____________________________________________________________________________________

Oral & Feeding Habits

Does your child have any feeding di culty with the following: ( )Poor suck ( )Di culty swallowing ( )Di culty swallowing

( )Gag/choke often ( )Finger feeding ( )Spoon use ( )Requires a feeding tube ( )Re ux/vomitting ( )Other: __________________________

Is your child a picky eater? Y / N

Does your child dislike particular textures of food? Y / N

Was your child breast fed? Y / N If YES, until what age? _____ Bottle fed? Y / N Combination? Y / N

Does your child use a paci er or suck thumb? Y / N If YES, how often? __________

Does your child use a bottle? Y / N If YES, how many per day? _____

Is your child a “mouth breather”? Y / N

If applicable, how old was your child when he/she discontinued use of: Paci er _____ Bottle _____ Thumb Sucking _____

Play Habits

Please check the types of play your child engages in most often: ( )Throwing and shaking toys ( )Games with rules ( )Rough and tumble play

( )Make believe play ( )Banging toys together ( )Mouthing toys ( )Pushing/pulling toys ( )Looking at books

What is your child’s favorite playtoy/activity? _______________________________ Favorite Ipad App/Video Game? _____________________

Does your child throw excessive tantrums? Y / N

Does your child prefer to play with older/younger children? Y / N Adults only? Y / N

Child’s School/Daycare Information

School Attending: _____________________________ Grade: _____ How often? ___ days per week ___hours per day

Teacher’s Name: ______________________ Classroom type: _______________ ( )Resource Room ( )ESL Class

Does your child receive any services through school? Y / N If YES, what services? ______________________________

Therapist’s Name: _____________________________ Phone Number: ______________________________________

Does your child have a current Individualized Education Plan (IEP)? ( ) Yes ( ) No

If YES, please provide a copy of your child’s IEP before evaluation, required for Medicaid Prior Authorization.

Emergency Contact Information

Last Name: _________________________ First Name: ________________________ Relation: ( ) Emergency Contact ( ) Parent ( ) Guardian

Home Address: ________________________________________________ City: ________________________State: _________ Zip: _________

Home Phone: _______________________________Cell Phone: ____________________________ Work Phone: _________________________

Who is authorized to pick-up child? _______________________________________________________________________________________

Additional Information

Any additional concerns you would like to share with us? _____________________________________________________________________

What goal would you like your child to work on this year? _____________________________________________________________________

Do you have any questions for us? ________________________________________________________________________________________

Please explain why you would like this evaluation done: ______________________________________________________________________

Thank you for taking the time to complete this form.

Guardian Signature:____________________________ Date: ________________

New Patient History Intake Form Page 2

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