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 Relationship PhoneEmail Lives at same address as child Yes No If No, Where? Name First Last Relationship PhoneEmail Lives at same address as child Yes No If No, Where? Name First Last Relationship PhoneEmail 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 Patient Intake Information Referring provider and/or care team for child (including any specialists):Pediatrician Pediatrician Name Clinic Dentist Dentist Name Clinic Naturopath Naturopath Name Clinic Chiropractor Chiropractor Name Clinic Optometrist / Ophthalmologist Optometrist / Ophthalmologist Name Clinic Speech Therapist Speech Therapist Name Clinic Occupational Therapist Occupational Therapist Name Clinic Physical Therapist Physical Therapist Name Clinic Seattle Children's Specialists Seattle Children's Specialists Name Clinic Behaviorist Behaviorist Name Clinic Vision Therapist Vision Therapist Name Clinic Other Other Name Clinic Is 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, List Languages Spoken in the home? English Other (List): Home EnvironmentStairs to enter the home Stairs to enter the home How Many Stairs within the home Stairs within the home How Many Recreational 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 Gestation Full Term Full Term Weeks Gestation Birth was Vaginal Cesarian Breech Twins/Triplets Baby Was (Birth Order) of(Number of) ChildrenAnesthetic used (if applicable) Hours of Labor APGAR scores (if known):At 1 Minute At 5 Minutes At 10 Minutes Complications during delivery? Yes No If Yes, list Did your child require NICU intervention or special care nursery? Yes No If Yes, how long Birth Weight?PoundsOuncesAny complications / problems during early infancy? Yes No If Yes, list Medical HistoryAny family history that would be pertinent to your visit today? Yes No If Yes, list Does 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 Describe Respiratory/Breathing Respiratory/Breathing Describe Cardiac/Heart Cardiac/Heart Describe Stomach/Intestinal Stomach/Intestinal Describe Skin Sensitivities/Rashes Skin Sensitivities/Rashes Describe Muscular Muscular Describe Skeletal/Bones Skeletal/Bones Describe Bowel/Bladder Bowel/Bladder Describe Emotional Emotional Describe Other Other Describe Does 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 Where When Occupational Therapy Occupational Therapy Where When Speech Therapy Speech Therapy Where When Vision Therapy Vision Therapy Where When Other Other Where When Other Other Where When Have 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 Test By Whom Feeding 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 Skill Sitting without support Sitting without support Age They Mastered Skill Crawling on belly Crawling on belly Age They Mastered Skill Crawling on hands and knees Crawling on hands and knees Age They Mastered Skill Pulling self to stand Pulling self to stand Age They Mastered Skill Walking proficiently independently Walking proficiently independently Age They Mastered Skill Crawling up stairs Crawling up stairs Age They Mastered Skill Crawling down stairs Crawling down stairs Age They Mastered Skill Walking up stairs Walking up stairs Age They Mastered Skill Walking down stairs Walking down stairs Age They Mastered Skill First words First words Age They Mastered Skill Multiple word phrase Multiple word phrase Age They Mastered Skill Sentences Sentences Age They Mastered Skill Riding trike/bike Riding trike/bike Age They Mastered Skill Jumping Jumping Age They Mastered Skill Running Running Age They Mastered Skill Current StatusWeight Height My 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) Other My 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) Grade Teacher's Name Education 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 night Awake time in morning Number of times child wakes at night Nap Schedule Naps Per Day How 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 Describe My child is sensitive to touch My child is sensitive to touch Describe My child is sensitive to tastes or textures My child is sensitive to tastes or textures Describe My child has decreased sensitivity My child has decreased sensitivity Describe My child is overwhelmed easily My child is overwhelmed easily Describe My child craves a high level of activity My child craves a high level of activity Describe Nutrition/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 likes Foods my child does not like CommunicationCommunication 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 home Prior foster placements:Is your child aware of adoption: Yes No Contact with birth parents/family/prior foster placements: Yes No Other adoption information:NameThis field is for validation purposes and should be left unchanged.