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Evaluation Intake Form: Birth to Age 3Child’s Name:Birth Date: Preferred Name:Male/Female (please circle) Parent/Caregiver:Phone Number: Address:Email:Child lives with (circle one):Both Parents Mother FatherGrandparents Other: _______________Are there any guardianship/custody issues our office should be aware of? Yes/NoIf yes, please briefly describe: __________________________________________________Primary Language Spoken in the Home:Primary Care Physician:Medical Diagnosis:Primary Concerns/Reason for Referral:Has your child previously received therapy before? YES NO Circle all that apply: ST OT PT If yes, where were services received and for how long? ____________________________________Why did your child discontinue receiving services?_______________________________________Emergency Contact(s): ________________________________ Phone: __________________Hospital Preference: ________________________________________In the event that my child becomes ill or injured while in therapy and guardians/emergency contacts are unable to be reached, I authorize the provision of emergency medical services to my preferred hospital. I give consent for the administration of any treatment deemed necessary by the treating physician. I understand that I will be liable for any costs associated under this consent to treatment.Signature of Parent/Guardian: ____________________________ Date: __________FAMILYNames and ages of siblings. Names and nicknames of family members close to your child: (ie: ‘nona’/grandmother):Names of pets:SCHEDULEWhat time does your child nap?Does your child attend any regularly scheduled appointments or programs?Name : Days: Times:1.2.3.PRE-NATAL & BIRTH HISTORY:?Premature, How many weeks?_____ ?Full term ?Birth uneventful ?Birth eventful: Please describe Please describe any pre-natal issues:Was the child in the Newborn Intensive Care Unit? If yes, for how long?DEVELOPMENTAL MILESTONES: ?Sat at age: ?Walked at age: ?First words at age: ?Combined words at age: Please list any developmental milestones NOT met within appropriate timeframes: MEDICAL HISTORY: Please elaborate if any of the following are checked.?Hospitalizations ?Surgeries ?Medication ?Seizures?Breathing Problems/Asthma?Allergies Please list: ___________________________________________________?Ear infections How frequently? ______________ ?Frequent upper respiratory infections ?GERD- age diagnosed. _______ How treated? ________________ Have symptoms resolved? YES/NO?Eats well ?Picky eater ?Nutrition a concern: YES/NO Current Weight?_______ Height?________ ?Bottles fed per day: ________ Number of ounces: ______ Name of Formula:________________?Sleeps well? YES/NO ?Other: _________________________________________Please list all surgeries and dates: Please describe your child’s health in general:MEDICATIONS: please list all medicationsName of Medication What addressing? Dosage Side Effects1.2.3.4.HEARING:Has your child had any ear infections? If so, please list dates and treatment.Has your child had PE tubes placed?Has your child been diagnosed with hearing loss? YES/NO If yes, what type and severity? ___________________________ Does your child regularly wear aided hearing device? YES/NOList any hearing evaluations your child has had.Date:Where tested:Results:VISION:Has your child had his or her vision checked? YES/NOIf yes, what were results? _________________________________________Does your child wear corrective lenses? YES/NODoes your child have a history of Estropia, Strabismus, Patching or Eye drop prescriptions?If yes, please specify: ___________________________________________________________________DENTAL/ORAL HEALTH:Does your child regularly see a dentist? YES/NOIf yes, how often? _____________________________Does your child allow you to brush his/her teeth? YES/NOHas your child used a pacifier? ____________ If yes, at what age did the child stop?_________Pacifier currently used? ________________ If yes, list brand: _____________________Does your child put toys or objects in his or her mouth? ___________________________BEHAVIORAL CONCERNS:Please check all that apply:?Cries often ?Dislikes hair brushing ?Rocks self ?Frequent temper tantrums?Dislikes tooth brushing ?Is sensitive to light ?Poor attention span ?Sensitive to Sound?Anxious ?Has trouble making friends ?Avoids touch from others ?Poor attention span ?Trouble with changes in routine ?Always “on the go” ?Clumsy ?Weak MusclesComments: Is there anything else that you feel would be beneficial for us to know about your child? ................
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