Pediatric Intake Form

Basic Information

Name:
Address:
Birth date:
Sex:
Parents' Names:
Mother's Cell Number:
Emergency Number:
Mother's Email:
Primary Care Physician:
Date:
Information given by:
Interviewer:
Referred by:
Reports to be sent to:
Father's Cell Number:
Emergency Contact:
Father's Email:



General Information

Child lives with:

One Parent:

Is there a language other than English spoken in the home?

If yes, which ones?

Who speaks the language other than English, if so list?

Does the child speak the language other than English?

Does the child understand the language other than English?

What does the client do during the day?

Name of school/day care/classes attended:

Other children in the family:

Name



Age



Sex



Grade



Speech/Hearing Difficulties



 

Is there history of delays and/or difficulties in the family?

Is there history of psychological and/or mental health disorders?

Is there history of hearing loss?

Is there history of autism?

Is your child on a restrictive diet?

Prenatal and Birthing History

Weeks Gestation

Birth Weight

Birth Height

Birth Hospital

Did mom have any illnesses before or during her pregnancy with this client?

Any medications before, during or after birth taken by mother?

If so, which ones:

Any consumption of tobacco or alcohol before or during pregnancy?

Any difficulties before or during birth?

If yes, please explain

Is your child currently being fed by formula?

If yes, please list:

Is your child currently taking any medications and/or vitamins?

If yes, please list:


Family Medical History



Client Medical History

Has your child had any of the following, check the box that applies:



Developmental History

Slept through the night

Sat up alone

Ate solid food

Said first words

Tied own shoes

Dressed self

Fed self with fingers

Matched puzzles

Held head up

Ran

Fed self with a fork

Smiled

Responded to name

Asked questions

Used single words

Followed 1-step directions

Engaged in pretend play

Identifies shapes

Rolled over

Crawled

Walked

Rode a tricycle

Drank from a cup

Toilet trained

Fed self with spoon

Stood up alone

Walked up/down stairs

Ate finger food

Dressed independently

Pointed to objects

Played peek-a-boo

Cooed

Combined words

Engaged in talking

Identifies colors

Identifies animals


Means of Communication



Speech and Language Development




Is understood by family members

Is understood by an unfamiliar listener

Does your child’s speech volume fluctuate during the day?

Does your child use an augmentative device?

Feeding History



Feeding Strategies



Current Feeding Behaviors That Concern You



Any Problems (Current/Past)


Please check the box that describes your child’s current intake of each of the following food types:

Consistency

Regular Liquid

Thick Liquid

Stage 1/2 baby food

Food from blender

Ground/stage 3 food

Mashed table food

Chopped table food

Regular table food

Crispy food (crackers)

Chewy food (meat)

Crunchy food (carrot)

Does eat

Can eat

Cannot eat

Won't eat

Never Tried



Your Goals for Therapy



Behavioral History and Characteristics



Sensory Motor Skills Development

School History

Name of school attending:
Grade client is currently in:
Did he/she repeat a grade
Difficulties with academics:

Is your child able to recognize:

Is your child able to functionally read:

Is your child able to produce by handwriting:

Is your child able to produce by typing:

Hand dominance:

Preferred Activities