big sky pediatric therapy

the sky is just the beginning!

Patient Information

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Female Male

Responsible Party

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Emergency Contact Information

Insurance Information

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Patient History

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

Areas of Concern – 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/sounds
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
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 distractible
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

Please indicate if you are interested in any of the following:

Preschool Prep Program
Social Skills Group
Handwriting Camps
Executive Functioning Groups
Dyslexia Training
Wellness Programs

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