Patient Intake Form

Optimize Today's Wellness Therapy Solutions INC.

Doral Office 9600 NW 25 ST. SuitePH Daral, FL 33172 Homestead Office 13420 SV/ 314" St. Suite 169 Homestead, FL 33033 Fax: (786) 8003836

General Information / InformaciónGeneral

Child's name/Nombre del niño*

D.O.B / Fecha de nacimiento*

Date

Age / Edad

Parent's name / Nombre de los Padres*

Address / Direccion *

Address / Domicilio

Street Address Line 2

City / CiudadState / Estado

ZIP

Home telephone / Teléfono de la casa

Cell Phone/Teléfono celular

Email / Correo electrónico

example@example.com

Place of Birth / Lugar de nacimiento

Length of Residence in USA / Tiempo de residencia en USA

Physician's name / Nombre del doctor

Phone / Teléfono

Does the child live with both parents? / Vive el niño con ambos padres?

Names and ages of Brothers and Sisters / Nombres y edades de los hermanos y hermanas

Languages spoken at home / Idiomas hablados en casa

Languages spoken by the child/Idiomas hablados por el niño

Describe the child's Speech Language problem / Describa el problema de comunicación del niño

When was the problem first noticed? / ¿Cuándo se notó el problema?

Has the problem changed since it was first noticed? / ¿Ha cambiado el problema desde que fue notado?

Has any other specialist seen the client? If yes, indicate the type of specialist and when the child was seen/ ¿Ha sido visto el niño por otro

especialista? En caso afirmativo, indique la especialidad y cuándo el niño fue visto:

Has any other specialist seen the client? If yes, indicate the type of specialist and when the child was seen/ ¿Ha sido visto el niño por otro especialista? En caso afirmativo, indique la especialidad y cuándo el niño fue visto

Prenatal and Birth History / Historia clínica durante el embarazo y nacimiento

Was your delivery premature, normal, delayed, or cesarean? / ¿Fue su parto prematuro, normal, retrasado o cesárea?

Did you smoke or consume alcoholic beverages regularly during pregnancy? ¿Fumó o bebió alcohol durante el embarazo?

Did you have any infections, illness, accidents, or injuries during the pregnancy?/y? Tuvo infecciones, enfermedades, accidentes o golpes durante el embarazo?

When did you begin to receive medical attention for the pregnancy? / ¿Cuándo empezó a recibir atención médica con este embarazo?

What medications did you take during your pregnancy?/ ¿Qué medicamentos tomó durante el embarazo?

Where there any complications during the delivery? / iTTwo complicaciones durante el parto?

Did you receive medications during the delivery? / ¿Recibió medicamentos durante el parto?

What did the child weight at birth? / ¿Cuánto pesó el niño al nacer?

Did the child suffer any complication during at birth? / ¿Sufrió el niño de alguna complicación al nacer?

Developmental History / Historia clínica del desarrollo

How old was your child when / ¿Qué edad tenía el niño cuando?:

Sat without help / Se sentó sin ayuda

Walked without help / Caminó sin ayuda

Began to speak, language? /Empezó a hablar, ¿en qué idioma?

Began to combine two words / Empezó a combinar dos palabras

Began to combine three or more words / Empezó a combinar tres o más palabras

Began to crawl / Empezó a gatear

Said first words / Dijo sus primeras palabras

Has or has had the child any feeding problems? If yes, please describe / El niño ha tenido 0 tiene problemas para comer? Si los hatenido, por favor describalos

How is he response of the child to sound? / ¿Cómo es la respuesta del niño a los sonidos?

Medical History / Historia clínica

Has the child had any of the following illnesses? / ¿Ha tenido el niño alguna de las siguientes enfermedades?:

Asthma /Asma

Throat infection / Infección de la garganta

Bronchitis / Bronquitis

Ear infection. How many? / Infección de los oídos. ¿Cuántas?

Throat infection / Infección de la garganta Ear infection. How many? / Infección de los oídos. ¿Cuántas?

Convulsions/Convulsiones

Mumps / Paperas

Dehydratation/ Deshidratación

Dehydratation/ Deshidratación Epilepsy / Epilepsia High fever / Fiebre alta Tonsil infection / Infección de anginas

Bladder problems / Problemas de la vejiga.

Epilepsy / Epilepsia

Kidney problems / Problemas de los riñones

High fever / Fiebre alta

Pneumonia / Neumonia.

Mumps / Paperas Bladder problems / Problemas de la vejiga. Kidney problems / Problemas de los riñones Pneumonia / Neumonia.

Tonsil infection / Infección de anginas

Any other illness? / ¿Alguna otra enfermedad?

Educational History / Historia educacional

Does the child attend day care or preschool? / ¿Asiste el niño al colegio o guardería?

Signature / Firma*

Clear

Relationship to child / Parentesco con el niño*

Date / Fecha*

Date

Child's name

D.O.B / Fecha de nacimiento

Date

Sex

Age

School/Daycare

Address

Teacher & Room

Phone

Home Address

Home Phone

Cell

Email

example@example.com

hereby represent and acknowledge that I am the parent and /or legal guardian of the above named child, who is my lawful son/daughter. I also give authorization to Optimize Today's Wellness Therapy Solutions, INC.

Screen Occupational Therapy / Physical Therapy / Gross Motor Skills / Speech Language.Evaluate and provide Occupational / Reading, Physical and Speech Therapy Services (If medically necessary and has insurance coverage)

This permission is allowed while the above name child is at Optimize Today's Wellness Therapy Solutions office, school, daycare center, home, family member's home/any area that the undersigned leaves the child during the time of the child's appointment with Optimize Today's Wellness Therapy Solutions Inc., concerning the care and treatment of the above named child.

Ifurther give permission to Optimize Today's Wellness Therapy Solutions, Inc. to communicate with their child's physician, related health professionals, school officials, teachers, parents, family members as deemed fit in the sole discretions of Optimize Today's Wellness Therapy Solutions, Inc. concerning the care and treatment of the above named child.

Type of Insurance:Medicaid/HMOOtherMedicaid/Medipass

Primary Insurance ID #

S.S #

Secondary Ins urance ID #

Pediatrician Name

Phone #

Language spoken at home

Parent/Guardian Printed name

Parent/Guardian Signature

Clear

I have read and understood the notice of Privacy Practices.

By Signing the following, I hereby agree to have listed both Primary and Secondary insurances (If applicable) Failure to comply, may result in charges and penalties not covered by the insurance.

Al firmar la siguiente, acepto haber enumerado los seguros primarios y Secundarios (si corres ponde) incumplimiento puede resultar en cargos y multas no cubiertos por el seguro.

Parent/Guardian Printed Name*

Date*

Date

Parent Guardian Signature*

Clear

Optimize Today's Wellness Therapy Solutions INC.

Doral office 9600 NW 25 ST. Suite PI Doral FL 33,72 Homestead Office

13420 SV/ 314 St. Suite 169 Homesterd, FL 33033

With whom outside of Optimize Today's Wellness Therapy Solutions INC. may protected health information be shared? All reasonable efforts will be made to protect the confidentiality of your protected health Information.

Federal and State regulatory agencies for example, The Department of Health and Human Services, The United States Food

and Drug Administration, The National Institute of Health, or other domestic foreign government bodies is required by law and/or necessary for Oversight purposes.

The members of the O. T. Wellness Therapy Solutions, INC. Review Board.Other Researchers, Coordinators and health care providers participating in this research.

As well as, outside individuals or entities that have a need to access this information to perform functions on behalf of Optimize Today's Wellness Therapy Solutions, INC. and its affiliates (for example, insurers, legal advisors, data storage companies We recognize that some of those who receive protected health information may not have to satisfy the privacy requirements that we do and may re-disclose it, so we share this information only if necessary and we use all reasonable efforts to request that those who receive it take steps to protect your privacy.

How long will protected health information about me be used or shared with others? There is no scheduled date for your health information that is being used or shared for this research to be destroyed, because research is an ongoing process, during which information may be analyzed and re-analyzed in light of scientific and medical advances, or reviewed for quality assurance, oversight or other purposes.

Statement of privacy rights: - You have the rights to withdraw your permission for the researchers and participating with entities to use or share your protected health information. We will not be able to withdraw all of the information that already has been used or shared with others to carry out related activities such as oversight, or that is needed to ensure the quality of the study. If you want to withdraw your permission, you must do so in writing by contacting Optimize Today's Wellness Therapy Solutions, INC. - You have the right to choose not to sign this form. If you decide not to sign, you cannot participate in this research study. However, refusing to sign will not affect your present or future care and will not cause any penalty or loss of benefits to which you are otherwise entitled. - You have the right to request access to your protected health information that is used or shared during your treatment or payment for your treatment, but you may access this information only after the study is completed. - You have the right to receive a copy of this form after you have signed it.

I have read this form and all my questions about this form have been answered. By signing below, / acknowledge that / have read and accept

Yo confirmo haber recibido información de la notificación de normas de privacidad del profesional mencionadas anteriormente y que he

tenido la oportunidad de leerlo y entenderlo. Este consentimiento es requerido por la ley gubernamental.

Patient name (print) / Nombre del paciente*

Parent or legal guardian/Padre o representante legal*

Signature/Firma*

Clear

Date / Fecha

Date

Relation with the patient/Relación con el paciente.

OT WELLNESS

OT WELLNESS

NOTICE OF PRIVACY ACKNOWLEDGEMENT