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: *

Name of School or Daycare *

Grade Level *

Please describe the #days/week at which your child attends school/daycare: *

If not applicable, please indicate N/A.

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

What type of games, activities, or toys does your child enjoy? *

Emergency Contact Information

Name *

First

Last

Relation to patient *

Phone 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

Current Areas of Concern

These will be discussed in detail during your initial appointment.

What are your primary concerns/goals for therapy regarding your child? *

Please check all that apply: *

Difficulty with latching on to breast or bottle Picky eater (avoids certain food tastes or textures) Difficulty with managing food in mouth (overstuffs and/or difficulty with chewing) Difficulty with drinking from cup or straw Constantly on the go Sensitive to clothing (i.e. tags) or certain textures (i.e. distress with messy hands/face) Overwhelmed in noisy environments Decreased body awareness (clumsy, seems to run into objects/people often) Hesitant to climb the jungle gym, slide down the slide and/or avoids swings Takes excessive risks, appears to have decreased safety awareness Difficulty dressing self Difficulty feeding self with utensils Difficulties with grooming tasks (brushing teeth, brushing hair) Difficulty managing small items such as beads or buttons Poor pencil grasp Decreased hand strength and/or endurance (i.e. appears to have weak hands, complains of hand fatigue) Difficulty opening containers or difficulty pulling socks on/off Difficulty completing puzzles Difficulty drawing shapes Poor handwriting (i.e. reverses letters, difficulty with letter formation, difficulty with letter sizing and/or spacing) Torticollis Head shape concerns Delay in sitting unsupported Delay in crawling Delay in walking Weak arms, legs or trunk Body is “floppy” Tires easily Increased muscle tone in arms or legs Uncoordinated Poor eye-hand coordination Poor balance Walks on toes Falls frequently Difficulty with climbing stairs without hand railing (if over 3.5 years old) History of sports related injuries (please specify below) Chronic pain (please specify below) Joint pain (please specify below) Has difficulty imitating demonstrated actions or movements Frequent emotional outbursts Frequently stubborn or uncooperative Easily frustrated when unsuccessful Difficulty tolerating changes in routine Difficulty attending to a task until completion Difficulty completing sequence of actions for familiar, everyday routines (i.e. often does things in the wrong order, difficulty following daily routine) Difficulty completing multi-step directions and/or tasks with multiple steps Poor organizational skills, including difficulty keeping track of toys or belongings Demonstrates minimal eye contact Difficulty following simple directions No verbal language Uses gestures more than words/sounds to communicate My child does not combine 2-words together Frequently repeats other people's spoken words/sentences My child has difficulty with responding to his/her name even though hearing is within normal limits Demonstrates disfluent speech (stuttering moments) Has hoarse vocal quality Demonstrates difficulty producing one or more of the following sounds: p, b, m, w, h, n Demonstrates difficulty producing one or more of the following sounds: t, d, k, g, f, v, y Demonstrates difficulty producing one or more of the following sounds: l, s, z Demonstrates difficulty producing one or more of the following sounds: sh, ch, j, th Demonstrates difficulty producing one or more of the following sounds: r

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

Medical History

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: *

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

If not applicable, please indicate N/A

If your child has required any surgeries or hospitalizations, please list which procedures or reasons and approximate date: *

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

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: *

Check all that apply: *

History of reflux History of ear infections History of ear tubes N/A

All languages spoken at home and frequency (in %) of each language spoken: *

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? *

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 *

Age of first word *

Age of putting two words together *

Running *

Jumping *

Currently receiving services from other healthcare professionals: *

Physical Therapy Occupational Therapy Speech Therapy Psychological Behavioral Therapy Chiropractor Other N/A

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: *

Insurance Information

Will you be filing with your insurance plan? *

Yes No

Insurance Company *

*Note: We are not accepting new Aetna patients at this time. We are not in network with Superior HealthPlan.

Primary Insured Name *

First

Last

Primary Insured DOB *

Insured's Relationship to Patient *

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 *

How did you hear about us? *

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
Join Our Team
- Careers
- Volunteer