DATE
PATIENT'S NAME (LAST, FIRST)
DATE OF BIRTH
MALE
FEMALE
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE NUMBER
EMAIL ADDRESS FOR RECEIPTS
PARENT'S/GUARDIAN'S NAME
DATE OF BIRTH
CELL PHONE NUMBER
SOCIAL SECURITY NUMBER
EMPLOYER
POSITION
PHONE NUMBER
RELATIONSHIP TO PATIENT
PARENTS'S/GUARDIAN'S NAME
DATE OF BIRTH
CELL PHONE NUMBER
SOCIAL SECURITY NUMBER
EMPLOYER
POSITION
PHONE NUMBER
RELATIONSHIP TO PATIENT
PRIMARY CARE PHYSICIAN
PHONE NUMBER
REFERING PHYSICIAN
PHONE NUMBER
DO YOU HAVE A PERSCRIPTION?
Yes
No
Parent/Guardian Marital Status:
Single
Married
Separated
Divorced
Other
Child lives with (check one):
Birth Parents
Foster Parents
One Parent
Adoptive Parents
Parent and Step Parent
Other
Child’s race/ethnic group:
Caucasian, Non-Hispanic
Asian or Pacific Islander
African-American/Black
Native American
Hispanic
Other
Is there a language other than English spoken in the home?
Yes
No
If yes, which one?
How did you hear about us?
Describe your child’s strong likes:
Describe your child’s strong dislikes:
What is your child’s favorite toy/activity/interests?
Patient’s preferred name if any?
Insurance Information
- Attach a photo of the front and back of the insurance card.
Front:
Back:
Primary Insurance Name:
Subscriber’s Name:
ID#:
Group#
Phone #:
Secondary Insurance Name:
Subscriber’s Name:
ID#:
Group#
Phone #:
BIRTH HISTORY
Baby was delivered:
Full-Term
Premature
week of gestation
Birth Weight:
Type of delivery:
Cesarean
Vaginal
Breech
This was a:
Single Birth
Multiple Birth (twins, triplets, etc)
Was there anything unusual about the pregnancy or birth?
Yes
No
If yes, please describe.
Did the baby pass the newborn hearing screening?
Yes
No
Did the baby experienced difficulties breathing?
Yes
No
Did the baby experience jaundice?
Yes
No
Was the baby placed on a feeding tube?
Yes
No
Was the mother and infant discharged separately from the hospital?
Yes
No
Please explain any YES answers:
Did the baby experience any early feeding/swallowing problems such as a weak suck, projectile vomiting, lack of appetite, early fatigue, etc)?
MEDICAL HISTORY
Has your child had any of the following?
Adenoidectomy
Encephalitis
Seizures
Chicken pox
Allergies
Flu
Sinusitis
High Fevers
Breathing difficulties
Head Injury
Sleeping difficulties
Thumb/finger sucking habit
Colds
Measles
Tonsillectomy
Tonsillitis
Mumps
Meningitis
Vision Problems
Pneumonia
Ear infections
How many?
Ear tube placement
When?
Are they still in place?
Yes
No
Other serious injury or surgery:
Is your child currently under physician’s care?
Yes
No
If yes, why?
Please list any medications your child (please include purpose of the medication)?
Does your child have any known allergies to food or to the environment?
Yes
No
If yes, please list
Does your child have any medical diagnoses? (e.g. ADD, Autism, dyslexia, CP)
Yes
No
Who/Where gave the diagnosis?
When?
Date of last hearing test:
Agency:
Results:
Are you concerned with the patient’s hearing?
Yes
No
EDUCATIONAL/THERAPY HISTORY
Name of school/daycare currently attending:
Present Grade
Does your child have an IEP?
Yes
No
Please check which services your child received in the past or is currently receiving?
Service Provided
Speech Therapy
Physical Therapy
Occupational Therapy
ABA Therapy
Special Education
Counseling/Social Work
Social/Play Group
How many minutes per week?
Where?
When?
PHOTO PERSMISSION
1. I give permission for photographs/videotape of my child for the purpose of treatment, education, and documentation.
Initial
2. I give permission for photographs/videotape of my child for website/Facebook.
Initial
Notice of Privacy Practices (HIPAA Acknowledgement/Consent)
I hereby acknowledge receipt of the Notice of Privacy Practices for ABC Pediatric Therapy, LLC. I hereby consent to the use and disclosure of my child’s protected health information (PHI) for the purpose of evaluation, treatment, payment, and health care coordination.
Initial
Thank you for your time in filling out this information regarding your child.
Completed by:
Relationship:
Date:
Attach a photo of your driver's license:
Speech and Language Information
Developmental Milestones:
Please tell the approximate age your child achieved the following developmental milestones:
rolled over
babbled
sat up without support
said first word
crawled
put 2 words together
cruised furniture
spoke short sentences
walked
toilet trained
Communication:
What is your main concern with your child’s speech and language?
Does your child show frustration with their speech and language difficulties?
Please list any relevant family history (speech/language/motor delays).
What is your main concern with your child’s motor development?
Has your child ever had a speech and language evaluation?
Yes
No
If yes, where and when?
What were you told?
What are your therapy goals for your child?
Indicate with a checkmark any items that are difficult for your child:
Eating a variety of food
Understanding what he/she hears
Following directions
Speaking in grammatically correct sentences
Answering questions
Pronouncing words correctly
Stating sounds of letters
Recognizing “common” words
Rhyming
Getting their point across
Telling stories
Thinking of words for things
Self-calming
Understanding concept of time
How would you describe your child’s primary method of communication?
Vocalizing/Grunting
Pointing/Gestures
Single Words
Sentences
Sign Language
Pictures
AAC Device
Feeding/Oral Motor
Do you have concerns with your child’s feeding? If yes, please describe.
How long have you been concerned?
Is your child’s weight gain a concern?
Does your child…
Drink from bottle
Yes
No
Eat with spoon and fork
Yes
No
Drink from a straw
Yes
No
Cough/gag while eating
Yes
No
Present as a picky eater
Yes
No
Drink from a sippy cup
Yes
No
Drink from an open cup
Yes
No
Drool
Yes
No
Pocket food in mouth
Yes
No
Have difficulty chewing meats or solid foods
Yes
No
Let you know when they are hungry
Yes
No
Sensory Motor Information
Please check any statement that describes your child:
Frequently trips on his/her own feet
Walks on his/her toes
Frequently bumps into furniture, walls, or other people
Needs cues to wipe face or hands when dirty
Has trouble sitting still
Chews on things such as his/her shirt, pens, toys
Avoids certain textures.If yes, which ones?
Gets “stuck” on toys/tasks/ideas and has a difficult time changing to another toy/task/idea.
Has trouble sleeping