Medical History Form for Big Sky Pediatric Therapy

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New Patient Intake Form

Patient Demographic Information

* Indicates required field

Patient's Legal Name *

First

Last

[object Object]

Date of birth *

MM/DD/YY

Sex: *

Male Female

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Parent/Guardian Name *

First

Last

Parent/Guardian Date of Birth *

Parent/Guardian's Marital Status *

Patient's Living Arrangement *

If "Other," please describe: *

Emergency Contact Information

Name *

First

Last

Relation to patient *

Phone Number *

Insurance Information

Will you be filing with your insurance plan? *

Yes No

Primary Insured Name *

First

Last

Primary Insured DOB *

Insured's Relationship to Patient *

Insurance Company *

Policy Number/ID Number *

Group Number *

Provider Phone Number *

Do you have a secondary insurance plan? *

Yes No

Insurance Company *

Secondary Insured Name *

First

Last

Secondary Insured Date of Birth *

Policy Number/ID Number *

Group Number *

Referral Information

Do you have a referral or doctor's order? *

Yes No

What therapy discipline are you interested in? *

Occupational Therapy Physical Therapy Speech Therapy Unsure

Select all that apply

Medical History

How did you hear about us? *

Pediatrician Name *

Pediatrician Phone Number *

Pediatrician Fax Number *

Please list all specialists involved in your child's care: *

Please list all food/drug allergies: *

If not applicable, please indicate N/A

Please list all current medications: *

Has your child's hearing and vision been checked within the last year? *

Yes No

If you answered yes, please choose from the results below: *

Primary language spoken at home: *

If your child has a medical diagnosis, please describe and list date of onset: *

If not applicable, please indicate N/A

Does your child present with aggressive behavior? If so, please describe how these behaviors present, what appears to cause these behaviors, and what appears to have helped calm your child in the past: *

If not applicable, please indicate N/A

If the mother had any complications during pregnancy, please describe: *

What was the length of pregnancy (i.e. weeks of gestation at birth)? *

Delivery type: *

What was the child's birth weight? (pounds, ounces) *

Were there any concerns or trauma during birth pertaining to your child? *

If your child has required any surgeries, please list with procedures and approximate date: *

Please indicate the approximate age (in months) at which your child met the following developmental milestones:

Rolling *

Sitting Unsupported *

Crawling *

Pulling to stand *

Walking *

Babbling *

First Word *

Putting two words together *

Running *

Jumping *

If your child has received any previous therapy services, please list type (OT, PT, or ST), duration, and age at which your child received the services: *

Please describe the frequency at which your child attends school/daycare: *

If not applicable, please indicate N/A.

School Name *

Grade Level *

Please list any therapy services received at school and the frequency of services: *

Areas of Concern

These will be discussed in detail during your initial appointment.

Please check all that apply: *

History of reflux Difficulty latching on to breast or bottle Weak suck Excessive drooling Unable to drink from cup or straw Overstuffs mouth with food Gagging during feeding or with the sight/smell Avoids certain food tastes/textures Difficulty chewing foods Picky eater Difficulty with pronouncing words/sound Echolalia (repeats common words/phrases) Has a limited vocabulary Poor social interaction Difficulty understanding simple directions No verbal language Doesn't seem to understand social cues Hard to understand your child Numerous ear infections History of Pressure Equilizing tubes ("tubes in ears") Weak hands Poor pencil grasp Difficulty dressing self Child has no hand dominance Poor handwriting Poor hand eye coordination History of sports related injuries Chronic pain Joint pain Weak arms, legs, or trunk Body is "floppy" Body is stiff Uncoordinated Clumsy Difficulty climbing stairs Poor balance Unable to catch a ball Unable to kick a ball Walks on toes Delay in sitting unsupported Delay in crawling Delay in walking Increased muscle tone in arms and legs Uncoordinated running pattern Easily distractable Difficulty attending to a task until completion Irrational fears Extreme fear of feet leaving the ground Distress with touch of certain textures Distress with messy fingers/face during mealtime Little regard to safety Overly cautious Unconsciously spins or rocks self Difficulty reacting when routine changes Little eye contact Unable to play with peers Refusal to obey Plays inappropriately with toys Difficulty sleeping Fixates on videos or TV shows Lines up objects and toys My child has difficulty reading compared to his/her peers My child has difficulty responding to his/her name even though hearing is within normal limits My child has difficulty in school My child cannot complete assigned work on time My child has difficulty completing the same amount of work as peers My child has frequent temper tantrums My child prefers not to cuddle with me Other

Please list any additional information or concerns you have regarding your child: *

Please read and accept the Terms & Conditions before submitting the form.

I have read and I accept the terms and conditions as put forth above *

Yes

Submit

We HOPE TO SEE YOU SOON!

Hours

M-F: 9am-6pm

Telephone

512-306-8007

Email

info@bigskyfriends.com

Home
Services
About Us
- Meet Our Team >
Getting Started
Contact
Events
Join Our Team
- Careers
- Volunteer