Contact InformationParent / Legal Guardian Name* First Last Phone*Email* Patient InformationName* First Last Date of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleChild lives with both parents?YesNoAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country School or Daycare (please include school, grade and teacher)What is your chief concern about your child?Insurance InformationInsurance ProviderPolicy Holder Name First Last Relationship to Policy HolderPolicy NumberGroup NumberMedical InformationPediatricianCurrent MedicationsAny diagnosesAre immunizations current?If no, please explainAllergiesPrevious hospitalizations/surgeries (please include reason, dates, and length of stay)Other doctors (dentists/psychologists/specialists) that provide care to this childPrevious therapy history (please include how long and by whom)Any hearing or vision difficulties (tubes, ear infections, etc)Prenatal/Birth HistoryFull termYesNoBirth WeightDelivery TypeVaginalCesareanBreechFeet FirstIf no, how many weeks?Illnesses or accidents during pregnancyMedications used during pregnancyLength of LaborWas labor induced or spontaneousAny fetal distress, oxygen required, etcDid your child require NICU care? If so, how long?Developmental HistoryPlease indicate the age when your child did the following (If you cannot remember exactly, indicate if it was expected or delayed) Sat up aloneCrawledWalkedMake wants/needs knownEat pureed fruits/veggiesEat pureed meatsEat raw fruits/veggiesUsed a strawUsed cup without lidHas your child had any feeding difficulties? Please explainDoes your child choke while eating? If yes, on what foods?Is your child a picky eater? If yes, what foods are preferred?Does your child drool excessively?YesNoHave difficulty gaining weight?YesNoDid or does your child suck their thumb or use a pacifier?Speech and Language DevelopmentHow well is your child understood by Primary parent/guardian:Other parent/guardianUnfamiliar AdultsDescribe what it is like to have a conversation with your childLanguage(s) spoken at homeChild’s primary languageWhat age did your child say first words?What age did your child say first phrases?What age did your child say first sentenses?How many words can your child say? Please list if fewer than 15What is the primary method your child uses to communicate wants/needs?Looking at objectsPointing at objectsGesturesCryingVocalizing/gruntingPhysical manipulationSingle words2-3 word combinationsSentencesDoes your child have difficulty following directions? Please describeDoes your child have difficulty producing certain sounds? If yes, which ones?Which of the following best describes your child’s speech?Easy to understandDifficult for parents to understandDifficult for others to understandAlmost never understood by othersWhich of the following best describes your child’s reaction to his/her speech?Easily frustrated when not understoodDoesn’t seem awareAttempts to say sounds/words more clearly when askedIs there a history of speech or language difficulties in the family? Please explainBehaviorDescribe your child’s behavioral characteristics. Check all that apply Cooperative Attentive Withdrawn Stubborn Aggressive Impulsive Inappropriate behaviors Self abusive behavior Poor eye contact Play SkillsDoes your child make friends easily, play well with others? Please describeWhat is the length of time your child can stay playing at one activity?What activity seems to hold your child’s attention for the longest period of time?What activity seems to hold your child’s attention for the shortest period of time?Does your child have tantrums? If yes, please describeWhich of the following describes the type of play your child likes to engage in the most often?Putting toys in mouthBanging toys togetherThrowing toysShaking toysPushing/pulling toysRole-playingActing out familiar routinesGames with rulesRough and tumble playLooking at booksSelf-CarePlease indicate whether your child can do the following independently Take off Socks Take off Shoes Take off Pants Take off Shirt Put on Socks Put on Shoes Put on Pants Put on Shirt Fasten Velcro Fasten Buttons Fasten Zipper Fasten Snaps Fasten Shoes laces (Meals) Finger Feed (Meals) Use fork (Meals) Use spoon (Meals) Use knife (Meals) Drink from cup (Hygiene) Urinate (Hygiene) BMs (Hygiene) Wash hands (Hygiene) Brush teeth (Hygiene) Brush hair (Hygiene) Bathe Please indicate whether your child can do the following with help Take off Socks Take off Shoes Take off Pants Take off Shirt Put on Socks Put on Shoes Put on Pants Put on Shirt Fasten Velcro Fasten Buttons Fasten Zipper Fasten Snaps Fasten Shoes laces (Meals) Finger Feed (Meals) Use fork (Meals) Use spoon (Meals) Use knife (Meals) Drink from cup (Hygiene) Urinate (Hygiene) BMs (Hygiene) Wash hands (Hygiene) Brush teeth (Hygiene) Brush hair (Hygiene) Bathe Sensory ProcessingDoes your child seem over or under sensitive to any of the following? Please describe SoundsTouchMovementLightPainTemperatureClothingCompleted by* First Last Relationship*Date* Date Format: MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
