InstagramThis field is for validation purposes and should be left unchanged.Pediatric Intake Form (Children ages 3+) We are requesting that you please take 10-15 minutes to fill out this valuable intake form. We appreciate your time and look forward to working with you and your child.Date MM slash DD slash YYYY General Information:Child's Name First Last Date of Birth MM slash DD slash YYYY Address Street Address Address Line 2 City 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 State ZIP Code Parent / Guardian Name(s) & Relationship to Child: Name First Last RelationshipPhoneEmail Lives at same address as child Yes No If No, Where?Name First Last RelationshipPhoneEmail Lives at same address as child Yes No If No, Where?Name First Last RelationshipPhoneEmail Lives at same address as child Yes No If No, Where?Emergency Contact InformationName First Last PhoneAddress Street Address Address Line 2 City 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 State ZIP Code Relationship to PatientIntake Information Referring provider and/or care team for child (including any specialists):Pediatrician Pediatrician NameClinicDentist Dentist NameClinicNaturopath Naturopath NameClinicChiropractor Chiropractor NameClinicOptometrist / Ophthalmologist Optometrist / Ophthalmologist NameClinicSpeech Therapist Speech Therapist NameClinicOccupational Therapist Occupational Therapist NameClinicPhysical Therapist Physical Therapist NameClinicSeattle Children's Specialists Seattle Children's Specialists NameClinicBehaviorist Behaviorist NameClinicVision Therapist Vision Therapist NameClinicOther Other NameClinicIs your child experiencing any pain? Yes No If Yes, Where is their pain located?How often do they complain of pain?What treatments for pain have you tried?Others in the home? Siblings Other family members Other caregivers Animals in the home If Yes, ListLanguages Spoken in the home? English Other (List):Home EnvironmentStairs to enter the home Stairs to enter the home How ManyStairs within the home Stairs within the home How ManyRecreational Activities / Sports (if any) my child participates in:The reason I was referred to therapy by my healthcare provider / what my concerns are?My goals for the therapy assessment are: Add RemovePrenatal/Birth HistoryAny difficulties or complications during the pregnancy? Yes No If Yes, list for the mother:If Yes, list for the child:Length of Pregnancy:Premature Premature Weeks GestationFull Term Full Term Weeks GestationBirth was Vaginal Cesarian Breech Twins/Triplets Baby Was (Birth Order) of(Number of) ChildrenAnesthetic used (if applicable)Hours of LaborAPGAR scores (if known):At 1 MinuteAt 5 MinutesAt 10 MinutesComplications during delivery? Yes No If Yes, listDid your child require NICU intervention or special care nursery? Yes No If Yes, how longBirth Weight?PoundsOuncesAny complications / problems during early infancy? Yes No If Yes, listMedical HistoryAny family history that would be pertinent to your visit today? Yes No If Yes, listDoes your child have any diagnosed medical conditions: Yes No If yes, please list diagnoses and year it was diagnosedDiagnosisYear Add RemoveMy child has the following difficulties? DescribeSeizures Seizures DescribeRespiratory/Breathing Respiratory/Breathing DescribeCardiac/Heart Cardiac/Heart DescribeStomach/Intestinal Stomach/Intestinal DescribeSkin Sensitivities/Rashes Skin Sensitivities/Rashes DescribeMuscular Muscular DescribeSkeletal/Bones Skeletal/Bones DescribeBowel/Bladder Bowel/Bladder DescribeEmotional Emotional DescribeOther Other DescribeDoes your child have any diagnosed or suspected allergies (or intolerances)? Yes No If Yes, list intolerance/allergy and reaction:Intolerance/AllergyReaction Add RemoveHas your child had any illnesses (chicken pox, measles, etc.)? Yes No If Yes, list illness and date(s):IllnessDate(s) Add RemoveHas your child had any hospital stays greater than 1 day? Yes No If Yes, list reason and date(s):Hospitalization ReasonDate(s) Add RemoveIs your child on any medications (prescribed or over the counter)? Yes No If Yes, list medication, dosage, and times per day administeredMedicationDosageTimes Per Day Add RemoveHas your child had therapy prior to your visit today?: Yes No If Yes, list where and whenPhysical Therapy Physical Therapy WhereWhenOccupational Therapy Occupational Therapy WhereWhenSpeech Therapy Speech Therapy WhereWhenVision Therapy Vision Therapy WhereWhenOther Other WhereWhenOther Other WhereWhenHave you tried any of the following therapeutic interventions in the past?: Therapeutic Listening Brushing Protocol Weighted Vest Home Sensory Diet Special Oral Diet: Gluten Free Cassin Free Dye Free Other Other:Does your child use any of the following equipment?Does your child use any of the following equipment? Hearing aids and/or Cochlear implant Glasses Feeding Tube Baclofen Pump Lower extremity orthotics Upper extremity splints Thoracic splint or brace Wheelchair Walker Stander Bath Equipment Other Hearing aids and/or Cochlear implant: Right Left Both Last Vision TestBy WhomFeeding Tube J Tube G Tube JG Tube Lower extremity orthotics Right Left Both Upper extremity splints Right Left Both Thoracic splint or brace SPIO Brace Other Wheelchair Manual Power Both Other Add RemoveDevelopmental History If applicable or known, please indicate when your child learned to do the following motor skills?Rolling independently Rolling independently Age They Mastered SkillSitting without support Sitting without support Age They Mastered SkillCrawling on belly Crawling on belly Age They Mastered SkillCrawling on hands and knees Crawling on hands and knees Age They Mastered SkillPulling self to stand Pulling self to stand Age They Mastered SkillWalking proficiently independently Walking proficiently independently Age They Mastered SkillCrawling up stairs Crawling up stairs Age They Mastered SkillCrawling down stairs Crawling down stairs Age They Mastered SkillWalking up stairs Walking up stairs Age They Mastered SkillWalking down stairs Walking down stairs Age They Mastered SkillFirst words First words Age They Mastered SkillMultiple word phrase Multiple word phrase Age They Mastered SkillSentences Sentences Age They Mastered SkillRiding trike/bike Riding trike/bike Age They Mastered SkillJumping Jumping Age They Mastered SkillRunning Running Age They Mastered SkillCurrent StatusWeightHeightMy child moves: My child does not move without support, dependent on caregiver for mobility Uses an assistive device On hands and knees Walking, holding a hand Walking, without using hands for support Other List device(s)OtherMy child goes up stairs: Does not go up the stairs On hands and knees (crawling) Walking holding a hand or a rail Walking without using hands for support My child goes down stairs: Does not go down the stairs On hands and knees (crawling) Walking holding a hand or a rail Walking without using hands for support My child's hand preference is Right Left Education Not applicable / not in school Homeschool Developmental Preschool School outside of home Name of School (if applicable)GradeTeacher's NameEducation Assistance My child has an IEP My child has a 504 Plan My child has a 1:1 Assistant My child is in a self-contained classroom / special education room Favorite subjects (if applicable):Subjects difficult for my child (if applicable):Education Other My child has good handwriting for their age My child has poor or below average handwriting for their age My child likes school My child does not like school Social SkillsWhen given a choice, does your child prefer to play alone or with others? Alone Others My child's play / peer interaction skills (check all that apply): Plays in parallel with peers Imitates peers Takes turns during games Shares well with other children Does not share well with other children Initiates others to play Takes turns during structured games Has difficulty taking turns during structured play Can follow others’ play ideas Avoids peers Easily learns to interact with new peers Struggles to interact with new peers Seeks others to play with Spends a lot of time in solitary pursuits (like solo video game or iPad playing) Has unusual interests or very limited interests Has multiple friends Has no or few friends Has been bullied Emotional SkillsMy child's emotional skills: Can identify likes/dislikes Can identify emotions in self Identifies emotions in others Demonstrates affection towards peers/others Demonstrates empathy towards peers/others Demonstrates aggressive behavior towards others Shows confusion over how to make friends or respond to other people Demonstrates aggressive behaviors towards self Displays sadness over social difficulties Demonstrates intense fears Gets angry easily Becomes extremely anxious, has panic attacks or experiences social anxiety around others Shows little to no empathy toward others Other emotional observations of my child:Any specific behavior problems noted in the course of your child's development?Sleeping Schedule/RoutineBedtime at nightAwake time in morningNumber of times child wakes at nightNap ScheduleNaps Per DayHow Long?Sleeping Schedule Other It is difficult for my child to get to sleep It is difficulty for my child to stay asleep I would consider my child a good sleeper SensoryMy child does not have any sensory difficulties My child does not have any sensory difficulties My child is sensitive to sounds My child is sensitive to sounds DescribeMy child is sensitive to touch My child is sensitive to touch DescribeMy child is sensitive to tastes or textures My child is sensitive to tastes or textures DescribeMy child has decreased sensitivity My child has decreased sensitivity DescribeMy child is overwhelmed easily My child is overwhelmed easily DescribeMy child craves a high level of activity My child craves a high level of activity DescribeNutrition/FoodNutrition/Food My child does not take food by mouth My child feeds themselves with their hands (finger foods) My child feeds themselves with utensils (fork/spoon) My child is a picky eater My child overstuffs mouth with feeding My child enjoys a large variety of foods / textures Foods my child likesFoods my child does not likeCommunicationCommunication My child is non-verbal My child uses sign language My child uses words for communication My child can speak sentences for communication Other people understand what my child is saying I have to support my child by interpreting what he is saying to others OtherMy child's favorite activities are:My child's strengths are:Thank you for taking the time to fill out this form. It will provide our therapy team with the information that will facilitate a more streamlined assessment and treatment for your child.Optional - Adoption/Foster Placement InformationDescribe circumstances surrounding adoption/foster placement:Age when adopted or placed in homePrior foster placements:Is your child aware of adoption: Yes No Contact with birth parents/family/prior foster placements: Yes No Other adoption information:
