Patient Appointment Form OT ST PT Patient InformationDate* MM slash DD slash YYYY Referred byPatient Name*Date of Birth* MM slash DD slash YYYY Age*Please enter a number from 1 to 100.Sex*FemaleMaleParent's Name*Home Phone*Mobile Phone*Email Address* Address 1 Address 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Primary Concern/DiagnosisPrescription from Doctor? Yes No Therapy Evaluation InformationPrimary Care Physician’s NamePhone NumberFax NumberReferring Physician’s NamePhone NumberFax NumberInsurance InformationName of InsuranceID #Group #Primary InsuredDate of Birth MM slash DD slash YYYY SSNEffective Date MM slash DD slash YYYY EmployerFor OT EvaluationsDoes your child have difficulties with any of the following?Self Care Skills: Buttons Clothing Zippers Sensory: Textures Body Awareness Transitions Fine Motor: Scissors Containers Utensils Pre-Writing/ Writing: Coloring Shapes Letters Gross Motor: Strength Coordination Ball Skills Social/Emotional: Friendships Emotional Regulation For feeding concernsIs your child on a limited diet? Yes No Is your child a picky eater? Yes No Does your child prefer certain temperatures? Yes No HotColdDoes your child only eat certain textures? Yes No SmoothCrunchyCurrent WeightWeight lost? Yes No General Development comments A good sampling of foods that your child prefers Some foods they will occasionally eat Several foods they DO NOT LIKE A drink (juice, milk or formula) Containers they usually use (cup, bottle, bowl, spoon, etc.) For ST EvaluationsHow does your child communicate? Single Word Short phrases gestures/signs communication device How much do you understand when they speak?(in %) Intelligibility articulation sound errors Do you have concerns with: Social Skills/Pragmatics interaction with peers/siblings Any concerns mentioned from teachers or pediatrician regarding their Speech/Language:What is the PRIMARY language spoken at home?For PT EvaluationsDoes your child have a medical diagnosis? Down Syndrome Austism Other If your child is under 12 months old, do they have any of the following diagnosis? Torticollis Plagiocephaly Delayed Milestones Other If your child is over 12 months old, do they have any of the following diagnosis? Low (soft) muscle tone High(stiff) muscle tone Gross motor delays Toe walking Fear of movement Balance issues or fall frequently pain w/ activity issues w/ stairs, curbs ETC Ride a bike, skateboard Uses adaptive equipment (wheelchair, walker, orthotics?) CommentsCAPTCHA
