Child Intake Form Page 2
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4History:
Any complications during prenatal period or delivery___________________________________________________________
________________________________________________________________________________________________________
Problems during your developmental milestones of walking, talking or potty training________________________________
___________________________________________________________________________________________________
Describe strengths and challenges during early childhood/Elementary School____________________________________
________________________________________________________________________________________________________
Current/Past
Medication
Dosage
Reason Taken
Start Date
Prescriber
______________________________________________________________________________________________
______________________________________________________________________________________________
_____________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Medical History:
Describe any major medical problems or head injuries _________________________________________________________
___________________________________________________________________________________________________
Describe any hospitalization: _______________________________________________________________________________
________________________________________________________________________________________________________
Physical Concerns
Please check all that apply
Motor
Headaches
Dizziness
Nausea or vomiting
Excessive fatigue
Urinary incontinence
Bowel problems
Weakness
Problems with fine motor control
Tremor or shakiness
Tics or strange movements
Balance problems
Bumps into things
Blackout spells/fainting
Other motor problems____________________________________
Sensory
Numbness/loss of feeling
Tingling or other sensation
Difficulty telling temperature
Visual impairment
Wear glasses
Sensitivity to light
See things that are not there
Brief periods of blindness
Hearing loss
Wear hearing aide
Ringing in ears
Hear strange noises
Problems with taste
Problems with smell
Pain
Other sensory problems________________________________________________________________________
Intellectual concerns
Problem Solving
Difficulty figuring out how to do new activities
Difficulty figuring out problems most others can do
Difficulty planning ahead
Difficulty changing a plan or activity
Difficulty thinking quickly
Difficulty completing tasks or activities
Difficulty doing tasks in an efficient order
Other concerns with problem solving___________________
Stone Arch Psychology and Health Services Child Intake
Page 2
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