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Download this
Parent Intake Form
as a printable PDF File of this page
Occupational Therapy Intake Screening Form
for All Children
If
your child is school age, please fill out both
this form and the OT Intake form
for School Age Children, here.
Copyright 2004 by Simoneon Pediatric Development Center. All rights
reserved.
Child's
Full Name: _______________________________________________
Parent's Full
Name(s): ____________________________________________
Child's Birth date: ____________________ Today's Date:
_______________
Mailing Address: ________________________________________________
Home Phone: _____________________ Other Phone(s): _______________
Fax: ____________________________ Email(s): ____________________
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Please circle all items of
past and current concern for your
child:
Health
-
Frequent ear infections or sinus infections.
-
Catches colds and/or the flu frequently.
-
Diagnosed medical condition, which restricts physical activity (i.e. heart
problem, asthma).
-
Has a confirmed diagnosis, which may be related to delays in development (i.e.
seizure disorder, breathing or heart problem, autism, Down Syndrome, cerebral
palsy or other). Please specify__________________________________________
-
Has a chronic medical condition (i.e. asthma, digestive disorder, heart
problems, etc.) Please specify __________________________________________
-
Has a communicable disease (Herpes, HIV, TB etc).
-
Requires such interventions as suctioning or special positioning.
-
Requires medication(s). If so, for what reason?____________________________
-
Has a feeding problem.
-
Has a nasal gastric or gastric feeding tube.
-
Has frequent diarrhea or constipation.
-
Has food allergies. If so, what?__________________________________________
-
Has environmental allergies. If so, what?__________________________________
-
Has medication allergies. If so, what?____________________________________
-
Wears hearing
aid(s)
-
Wears corrective lenses. If so, what correction?____________________________
-
Requires splints, bracing or other appliances for improving function.
Sensory Processing/Regulation
Sleep
patterns are or were irregular
Hunger
and/or thirst patterns are or were irregular or less/more than expected in
frequency
Alertness/arousal states often don't match others
Inability to
self-calm
Avoids or
resists stimulating experiences, preferring quiet and solitude.
When alone
or with immediate family, seems to be happier outdoors than indoors
Is often
bothered by environmental stimuli, which seems to go unnoticed by others
Behavior
deteriorates with schedule changes or when something happens which isunpredictable
Demonstrates
resistance to, anxiety or agitation with touch from others or proximity ofothers,
textures in food, hygiene activities, clothing textures and/or play materials
Becomes
agitated or overwhelms easily or becomes drowsy and sleeps in response to stimuli which overwhelm
Seeks out
(and seems to crave to excess) touch experiences
Seeks out
(and seems to crave to excess) such muscle/tendon/joint stimulation experiences
as jumping, bouncing, body slamming, pulling, pushing, climbing and swinging
from monkey bars
Seeks out
(and seems to crave to excess) self-rolling, self-spinning/twirling, somersaulting, diving off a diving board (in preference to swimming), swings,
slides, teeter
totters, skating, skateboarding, bike riding, fast moving carnival rides, hanging upside down
Avoids or
resists and seems fearful of the experiences in item # 13
Seeks out
(and may crave to excess) visually stimulating experiences such as brightly colored
lights or toys with lights, spinning objects, pendulums, metronomes, wind chimes or
play with hands, objects or light to create predictable, regular movementpatterns
Has
difficulty finding objects with a competing background (clothing in drawer, toys
in room, items in desk)
Attention
and distractibility issues arise with physical proximity of others, being touched,
anticipation of touch, noise, smells, visual stimuli and/or postural instability
Auditory, Speech
and Language Processing:
-
Has a
diagnosed hearing impairment
-
No diagnosed
hearing impairment, but not seeming to hear or process language aswell as
others’ do at this age
-
Does not
appear to enjoy being talked to, read to or sung to
-
Tires
easily, has limited attention or is easily distracted when listening
-
Has
difficulty hearing/functioning with noisy backgrounds
-
Confuses
similar sounding words or poor ability to discriminate different sounds
-
Difficulty
following conversations
-
Monotone
speech
-
Speech
(fluency, rhythm and/or sound articulation) skills delayed for age
-
Language
skills (sound production, vocabulary, content, elaboration of ideas, structure and/or organization) skills delayed for age
-
Responds
slowly or misses some of the communication intent or content from others
-
Difficult
for others to interpret child’s communicative intent
-
Seems to
ignore or lack interest when others are communicating
-
Difficulty
following conversations
-
Difficulty
interpreting non-verbal communication from others
-
Poor short
term auditory memory
-
Seems overly
sensitive to certain sounds and may cover ears, cry, scream or become aggressive
toward self or others, upon hearing those sounds
-
Seems to
enjoy making noises or strange sounds (may do so as a cover for other objectionable sounds)
Social-Emotional
Skills:
(many items
above are also relative to social-emotional skills)
-
Does not
relax with parent voice or parent touch
-
Is
indifferent to the presence or attention of familiar others
-
Does not
respond or appropriately respond to the facial expressions of familiar others
-
Preferring
to play alone, does not appear to enjoy interactive play with familiar others
-
Does not
initiate hugs and kisses, or resists hugs and kisses from familiar others
-
Does not
display vocally, or with facial expressions, a wide range of emotions (to
include anger, fear, sadness, joy, guilt, sympathy, anticipation)
Does not
attempt to comfort others in distress
Has no need
to be the center of attention
Cognitive Skills:
-
Relative to
age, is slow to learn new concepts or has difficulty retaining previously taught concepts
-
Relative to
age, difficulty understanding cause and effect relationships (as an infant this may be
demonstrated as different cries for different needs)
Relative to
age, is unmotivated or unable to play with age appropriate toys for their
intended purpose
Difficulty
as toddler with matching, sorting, doing simple puzzles
Difficulty
with visual or auditory memory, relative to age
Difficulty
problem solving, relative to age
Gross Motor Skills:
-
Appears
awkward or less coordinated than other children this age and may resist doing large motor
activities
-
Has
difficulty figuring out how to move body or takes more time to learn or perform
motor tasks, than
others this age
-
Balance
responses are immature or exaggerated for age
-
Falls more
frequently than other children this age
-
Has a poor
sense of the body in space, running into things
-
Seeks
external support for posture (leaning on furniture or people, slouching or lying down, versus sitting/standing erect)
-
Seems to
fatigue quicker than other children this age
-
Demonstrates
stiff or rigid movement patterns
-
Has most
difficulty with sequential or rhythmic motor tasks or tasks requiring
coordination
-
between
upper and lower body or between body side
Fine Motor and
Self-Help Skills:
-
Has or had
poor coordination of suck swallow and breathe (noticed with breast, bottle, cup and/or
eating solids)
-
Has or had
difficulty moving the tongue around the inside and outside of the mouth to manage food
-
Delay in
holding own bottle, cup, finger feeding and/or using spoon and fork
-
Delay in
responsiveness to assist with dressing (by putting out hand or foot)
-
Inability to
move the eyes independent of the head (with head and eyes moving together)
-
Delay in
establishing (at expected ages) regular sleep schedule and bowel/bladder control/schedule
Does not
show interest or ability to help with household tasks
Demonstrates
little interest in independence
Delays in
doffing/donning clothing and managing clothing fasteners
Difficulty
using school supplies appropriately (pencils, crayons, scissors, paste etc)
Difficulty
managing lunch supplies (food containers, zip lock bags, juice box and straw, milk cartons etc)
Relative to
age, has difficulty managing personal hygiene independently (tooth and hair brushing,
hand and body washing/drying,
Seems to
lack interest in self-help and/or fine motor activities
Has a
limited repertoire of hand skills or ability to use the hands to manipulate
objects appropriately, relative to age
Has
difficulty using both hands at the same time (one hand is manipulating while the other is
stabilizing)
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