Initial Intake Form 2022

Initial Intake Form

PATIENT HISTORY AND BACKGROUND
Child's Name

First Name Parent
Date of birth

Month Day Year
Date
My child is going to be evaluated for:

Speech & Language Services Occupational Therapy AND/OR Physical Therapy
Parent/Caregiver Name

First Name Last Name
Parent Email
example@example.com
Occupation of parent/caregiver
Other Guardians/Alternative Care Providers

First Name Last Name
Occupation of additional parent/caregiver
How did you hear about Kids In Motion
Primary Doctor

BIRTH & MEDICAL HISTORY
List all medical conditions or diagnoses your child has been told they have or that you are suspecting?

Gestational Information

	Yes	Notes
C-Section
Breech
Failure to thrive
Underwieght
NICU Stay
Premature
Gestational Diabetes
Pre-Eclampsia
Maternal High Blood Pressure

Were there any difficulties during pregnancy or delivery?
Has your child had any of the following?

Difficulties with keeping head in one position (torticollis) Flat head History of foot deformities including club foot or metatarsus abductus History of hip displasia Xrays or ultrasound of the hip or neck Skin conditions, birth marks Lip Tongue Tie/Release Difficulty with latching for breastfeeding or bottle feeding
If yes, please explain?
Treatments tried (therapy, chiro, essential oils, diet restrictions, etc.)
What is your child currently doing well emotionally and developmentally? What are their strengths?
What are your PRIMARY concerns and primary problems regarding your child's development.
Medications and/or allergies?
Is your child currently in good health? Past surgeries or imaging and injuries?
Living Environment: Please describe your home?
Who lives in your home?
Is there any similar diagnoses or problems in your family? Please describe:
Are there any precautions the therapist should be aware of when working with your child?
Safety Concerns:

Can't report getting hurt Frequently trips and falls No awareness of danger Inappropriate sexual behaviors Too impulsive Physical aggression towards others Does not learn from experience Unsafe around traffic / crossing the street Bolts/ runs off Has no "stranger danger" awareness Not safe around sharp or hot items Does not respect other's personal boundaries Easily influence by peers, could do something unsafe they say to do without thinking about the consequences Accidentally hurts self or others due to poor coordination Excessive number of accidents (bumps and bruises self often) Sudden outbursts Poor choices affecting safety Chokes on food or liquids Does not learn from experience Not safe around sharp or hot items Does not respect other's personal boundaries None
Describe your child as an infant:

Easy Average Alert Active Passive Quiet Enjoyed cuddling Sociable Difficult Colicky Cried a lot Fussy Resisted being held Floppy when held Tense when held Good sleep patterns Irregular sleep patterns Excessive restlessness Head banging I don't know (e.g. foster/adopted)
Does your child prefer one hand over the other?

Yes, Right handed Yes, Left Handed No I don't know
Describe how your child moves around their home or environment.

My child usually plays on the floor or is held Uses an assistive device such as crutches, walker, gait trainer Uses a power wheelchair Uses a manual wheelchair Walks and moves independently Walks and moves independently but falls a lot My child has a prosthetic limb
Assistive Devices

Shoe inserts or AFO/SMO Cane Walker Wheelchair Hoyer Lift Gait Trainer Stander Adaptive Vehicle Adaptive toilet seat Other special seating equipment Adaptive technology

SPEECH LANGUAGE
How much do you understand your child?

Never 0-25% of the time 26-50% of the time 51-75% of the time Greater than 75% of the time All the time
How much do less familiar people (grandparents, aunts, uncles, etc.) understand your child (0%-100%)?

Never 0-25% of the time 26-50% of the time 51-75% of the time Greater than 75% of the time All the time
Early Speech & Language Skills (Birth to 2 years Old)

Babbling Pointing or using gestures to communicate. Trying to imitate words Stopping/pausing when hearing “no” or their name Follows simple directions with gestures Follows simple directions without gestures. Uses sounds /p, b, m, n, d, w, h/ when babbling or using words Waves or says “hi” or bye Listens to short stories, songs, or rhymes

Speech & Language (3 and above years)

	Yes	No	Sometimes
Following directions similar to peers
Uses sentences to communicate wants and needs
Answers yes/no questions
Answers “wh-“ questions
Asks Questions
Engages in conversation
Can state personal information when asked
Retell a story
Uses grammatically correct sentences
Respond to Greetings
Make Requests
Describe Events
Take Turns
Follow Commands
Make Eye Contact
Repeat
Attend to Tasks
Maintain Topic
Role-Play
Sequence Actions
Define Words
Categorize
Understand Object Functions
Initiate Activity or Dialogue

Fluency

Gets stuck on words Can’t get their thoughts across in a single sentence Repeat words Holds a sound out longer than normal
Voice

Raspy voice horse sounding Pitch appears higher than peers

FEEDING
Do you have concerns with eating, mealtimes, drinking, and variety of foods? If you answer no, please move on to next section. *

Yes No

Swallowing & Feeding

	No	Sometimes	Often	Always
Fatigue easily during meals
Choke/coughing when eating or drinking
Are messy eaters
Difficulty drinking from a straw or open cup
Difficulties with swallowing during/after drinking or eating
Difficulty with liquids
Difficulty with foods
Difficulty swallowing medicines
Reports feeling "lump" in throat
Complaints of pain when swallowing
Wet or gurgly voice after swallowing
Pocketing food in cheeks
Unexplained weight loss
Indigestion or burning reported
Coughing or choking while eating/drinking
Acidy or metallic taste in mouth upon waking
Longer time to finish meals
Throat clearing after swallowing
Dry Mouth
Runny nose after eating

Feeding History

	Yes	No	Sometimes	Notes
Feeding tube
Breast-fed
Bottle-fed
Finger feeds
Cup with spout
Straw drinking
Spoon
Fork
Open cup drinking
Knife
Stage 1 baby food
Stage 2 baby food
Stage 3 baby food
Table foods
Sweet
Sour
Bitter
Bland
Salty
Spicy
Smooth purees (smmothie, applesauce)
Chunky purees (peas/carrots cooked)
Soft solids (ground hamburger, noodles)
Hard solids (steak, carrots, granola bar)
Hot foods
Warm foods
Room temperature foods
Cold Foods

How many meals does he eat a day with snacks?
Where does your family eat your meals?
Response to feeding

Arches back Choking Coughing Crying Difficulty chewing Drooling Eats too fast Eats too slow Fails to chew food Frequently changes nipple Gagging Getting down from table Hiccupping Holding food in mouth Nasal regurgitation Pockets food Poor intake Reflux Refuses to open mouth Refusing to eat Spillage of food/liquid Spits out food Stuffs mouth Throwing food/objects Turning head away Vomiting Wet vocal quality after eating

OCCUPATIONAL HISTORY
In one sentence how would you describe your child?
In one sentence how would you describe yourself?

CHILD PROFILE (FINDINGS)
My child often loses their balance:

No problems When not moving, they just seem unstable and will fall over When challenged with an activity or new environment Uses hands or things around our home to balance when moving
Behaviors in day to day routines:

Avoidant Behaviors with difficult tasks Decreased working memory affecting ability to learn Defiant behaviors Immature or inappropriate behavior for age Difficulty transitioning between activities Cries or fusses with interaction Decreased attention span Easily distracted by environment, sounds, noise Easily frustrated with challenging tasks Does not make eye contact appropriately Difficult to quiet at appropriate times Quiet but interactive Has difficulty sitting still Lacks confidence in their abilities Inappropriate use of toys Arm Flapping or motor tics Child requires encouragement for engagement in activities Unusual fears Difficulty learning new tasks Throws temper tantrums
Cognition

No concerns or not age appropriate My child has difficulty with telling time, identifying familiar places, people, or situations I feel like my child has difficulty with short term memory I feel like my child has difficulty with long term memory My child has difficulty with figure out the order of tasks My child has difficulty with problem solving simple tasks My child is unable to follow 1 step directions My child is unable to follow multiple step directions My child has difficulty with attention My child has difficulty initiating activities My child has difficulty with stopping an activity
Comments regarding cognition:
General Communication Skills

Able to communicate using gestures and pointing Difficulty expressing feelings and emotions Communicates primarily through pointing and gestures Parent/Caregiver communicates child's needs Non-Verbal Attempts to verbally communicate but is difficult to understand Difficulty understanding simple phrases Ignores verbal interaction Uses sign language Hearing impaired Uses communication board Learns best through demonstration Learns best with verbal direction Learns best with hand-over-hand demonstration Looks for source of voice Makes appropriate eye contact when speaking with child Vocalizes sounds but is not intelligible Difficult to quiet at appropriate times Is able to remain quiet at appropriate times
Endurance & Fatigue

My child is in good physical health I am worried about my child's physical health due to sedentary activity or obesity My child fatigues faster than other children in their peer groups My child naps often after physical activity My child appears to be out of shape or have difficulty with play due to poor endurance

Do you have concerns with any of the following higher level fine motor activities?

	Unable	Poor quality/coordination	Notes
Due to my child's diagnosis these are all difficult
Coloring
Cutting
Handwriting
Holding an object in each hand for at least 5 seconds
Locating objects in theraputty
Picking up small objects with tweezers
Picking up small objects

Do you have concerns with any of the following higher level gross motor activities?

	Unable	Poor quality/coordination	Notes
Due to my child's diagnosis these are all difficult
Going up and down stairs
Swing and pump legs
Heel to toe walking
Running speed and agility
Wheelbarrel crawling
Catch and throw a ball
Riding bicycle
Animal walks
Jumping
Climbing
Obstacle course/Climbing
Hops on one leg
Kick a ball
Bounce a ball
Crab crawling
Somersault

Motor Planning

My child has low muscle tone My child has high muscle tone My child has difficulty forming ideas and concepts for everyday activities or play It is difficult for my child to initiate and control their muscle function and voluntary movements. My child has difficulty with timing their muscles to complete tasks. Movements can be slow, off target, too fast

Posture

No concerns My child has poor posture when standing, sitting, squatting, bending My child has difficulty with uneven surfaces, running, biking, or higher level postural demands

	Notes
Where does your child complain of pain?
Is there anything that makes pain worse? Activities, events, clumsiness
Anything that helps it?
How does your child describe their pain

SENSORY PROCESSING SYSTEMS
Auditory

Responds negatively to unexpected or loud noises Holds hands over ears to protect from sounds Distracted / trouble functioning with noise Can't work with background noise Doesn't respond to being called by name Enjoys strange noises / makes noises Difficulty maintaining auditory attention Difficulty shifting from one task to another Distractible to irrelevant stimuli Slow adaptation to relevant auditory stimuli Difficulty understanding non-verbal cues Difficulty understading nuances of language Difficulty following a simple request with a verbal/motor response Difficulty with filtering of auditory input Dislikes noisy items such as vacuum, lawn mower, etc Difficulty selecting a primary message from background noise Easily distracted by environmental sounds Oversensitive to sounds / frequently covers ears Able to retain auditory information in order Difficulty retaining auditory information in order Under-aroused by incoming stimuli
Visual

Discomfort / avoids bright lights Happy to be in the dark Difficulty finding objects in busy background Bothered by bright lights Covers eyes or squints in lights Looks intensely at objects / people Easily distracted by environment Avoids eye contact Prefers to be in the dark Able to recognize shapes and forms Able to visually localize requested object from environment
Tactile

Avoids getting messy (paste, sand, paints, etc) Distressed during grooming Prefers long sleeve when hot / short when cold Discomfort with dental / brushing Sensitive to certain fabrics Irritated with socks / shoes Avoids going barefoot Reacts emotionally or aggressively to touch Withdraws from splashing water Difficulty standing close to others Rubs / Scratches spots that have been touched Unusual need to touch objects / people / surfaces Decreased awareness of pain / temperature Decreased awareness of touch Avoids wearing shoes / prefers barefoot Doesn't notice messy hands / face Distressed by changes in clothing
Oral

Gags easily with textures / utensils in mouth Avoids certain tastes, foods, smells Will only eat certain foods, tastes Limits self to food textures, temperatures Picky eater Frequently smells non-food objects Strong preference for certain smells Strong preference for certain tastes Craves certain foods Seeks out certain tastes, smells Chews or licks non-food objects Mouths objects (hands, pencils, etc)
Vestibular

Becomes anxious/distressed w/feet off ground Dislikes activites with head upside down Avoids moving equipment/toys Dislikes riding in a car Seeks movement activities Twirls/spins (likes dizzy feeling) Rocks unconsciously Rocks in desk/chair/floor Loves to spin, swing and jump Reluctance to engage in new postures and positions Slumped, rounded posture Uncomfortable with open spaces such as a shopping mall Uncomfortable with playground activities Uncomfortable with steps Uncomfortable with surface changes on the floor
Proprioceptive

Low muscle tone High muscle tone Avoids climbing or jumping Child does not move around or explore his environment Jumps excessively Poor gross and fine motor control Seeks deep touch pressure Seeks movement that interferes with daily life
Multi-Sensory Processing

Gets lost even in familiar places Difficulty paying attention Looks away from tasks to notice action in room Oblivious within an active environment Hangs on people / furniture / objects Walks on toes Leaves clothes twisted on body

Strength & Mobility

	Poor Strength	Poor movement/Mobility	Any thoughts?
Ankle
Elbow / Forearm
Hand - Strength
Hip
Knee
Shoulder
Spine
Wrist

Visual Motor Skills

Avoids eye contact Does not spontaneously track or look for target object Does not visually explore or examine an object Hesitates going up and down steps Prefers to be in the dark Illegible handwriting Talks to self while writing Watches hand while writing
Bowel and Bladder Function

No Concerns Wets bed Holds Urine or Stool due to fear or pain Frequent Urinary Tract Infections Night wetting Constipation Streaking in underwear Not Toilet trained
If you marked any Bowel & Bladder concerns, please describe below.

FUNCTIONAL ACTIVITIES (Exploring environments, play, leisure, school and daycare)

Mobility & Movement

	Does not get into this position	Needs Help	Independent
Prone on Elbows
Rolling
Prone to Sit
Sitting
Moving from Sit to Crawl
Crawling
Hands & Knees
Sit to Kneel
Tall Kneeling
Standing
Kneel to Stand
Walking

Developmental History

	Currently Unable To	Delayed	Met on Time	I don't know
Rolled by 7 mo
Crawled by 10 mo
Reached by 6 mo
Finger fed by 16 mo
Ate with spoon by 2 yr
Drank from open cup by 18 mo
Dressed self by 3 yr
Clothing fasteners by 4yr (tie bow by age 6)
Toilet Trained by 4 yr
Draw a circle by 3 yr
Cut with scissors by 4 yr
Use knife for cutting by 5 yr
Walked by age 13-16 mo
Jumped by 3 yr

What are your child's favorite activities or what do they love doing the most?
What does your child avoid or dislike the most?
Social Play Skills

Play alone Play next to other children Shares with other children Play with other children Engages in conversation
Comments:

Does your child have any difficulty with self care tasks?

	Needs Physical Help	Needs step by step verbal help	Needs Reminders	Can do it independently
Feeding self
Eating
Dressing
Grooming
Bathing
Sleeping
Personal Hygiene
Toileting
Transitions between activities

Please describe the problems with self care

EDUCATIONAL/THERAPY HISTORY
Is your child school age?

Yes No
Does your child attend daycare or preschool?

Yes No
Current classroom placement:

Regular classes My child is on an IEP Gifted classes Homeschool
Does your child comprehend directions as well as other children?

Yes No I Don't Know
Comments:
Has your child had to repeat a grade?
What grade is your child functioning in?
For example, above for math, below for reading, grade level for writing
Academically is your child:

Needs some help to accomplish class work Average Advanced
Socially and behaviorally is your child:

Functioning well, gets along with others, no behaviors Average, needs some assistance some times Struggles with making or keeping friendships, negative behaviors towards others or self or has difficulty with social groups Other
Do your child's teachers describe any of these problems?

Transitions Handwriting Attention Copying from Board Reading Homework Sitting at Desk Fine Motor Social Skills Recess Performance Sports Sit During Meal Frequently gets up and walks around Won’t wait for turn Does not respect the rights of others Does not cooperate well in groups Shouts out Does not wait to be called on Typically does better 1:1 Does not pay attention during circle time or lecture Difficulty with Individual work times Difficulty with small groups Difficulty with free play Difficulty with field trips/special assemblies /movies / class discussion
Specialists currently working with my child:

Outside agency such as HIT, ENABLE, Community Options My child receives respite Occupational Therapy -Community / Medical Occupational Therapy- School Speech Therapy Community / Medical Speech Therapy - School Physical Therapy -Community / Medical Physical Therapy - School Psychologist / Counselor - Community / Medical Psychologist / Counselor - School Behaviorist - Community / Medical Behaviorist - School Developmental Optometrist Specialist Physician Neurologist Orthopedist Reading Specialist / Tutor - Community Reading Specialist - School Writing Specialist / Tutor - Community Writing Specialist / Tutor - School Math Specialist / Tutor - Community Math Specialist / Tutor - School
Comments:
Please describe a typical day for your child from waking until bedtime (describe difficulties in routines such as going to sleep, staying asleep, etc) Please any information that will help us know your child better.
Activity Level

Given my child's diagnosis, the activity level is appropriate Mostly quiet Lethargic slow movements Tires easily Overly active Talks constantly Restless More active than siblings or other children same age Acts like driven by a motor
Comments:
How are your family's everyday activities affected by these concerns and problems? Are there things that you cannot do but would like to as a result of these concerns?
In one year, it would be amazing if my child could.......What goals do you have for your child related to therapy services? Please list 2 to 4 priorities that you would like to achieve.
What do you feel is limiting your child from doing this now?
Approximately when did you start noticing your concerns and is it getting better, worse, or staying the same in the past 6 months?

Environmental Supports and Barriers (please note barrier or supports specifically, for example, have a ramp with a van or can't ride the bus due to accessibility, or allergies prevent us from playing outside, can't afford healthy foods)

	Not a problem	Helps our family or is a resource we use	We lack resources in this area or feel this is a barrier	NOTE
Physical Layout of my home
Physical layout of places we go in the community
Sensory factors in the environment (allergies, lights, sounds, air quality)
Physical demands on parent or child
Cognitive demands on parent or child
Social demands on parent or child
Attitudes of teachers, staff, other supports
Child's peer relationships
Safety at school
Access to transportation
Programs and services availability
Supplies availability such as technology, toys, etc
Time that family members spend with child
Family and friends
Financial means and resources

What social supports does your family have or need?
Overall what is your level of concern?

1/10 Mild 2/10 Mild 3/10 Moderate 4/10 Moderate 5/10 Moderate 6/10 Moderate 7/10 Severe 8/10 Severe 9/10 Severe 10/10 Severe
Overall how often do you experience these difficulties with your child?

Multiple times a day Once a day 2x per week 3x per week 4x per week 5x per week 6x per week Other
As the primary caregiver to this child, I prefer to have information for home programming:

Discuss during services and provide me paper handouts Discuss during services and email me on an app I can use to track exercises with instructions and videos I am a visual learner I learn best by listening
Parent/ Legal Guardian's Signature

Clear
Date Signed:

Month Day Year
Date
Should be Empty:

	Likes	Dislikes or Avoids
Protein
Dairy
Vegetables
Fruits
Grains
Other

	Yes	No	Needs Help	Any thoughts?
Does your child feed himself?
Does he use fingers?
Does he use fork?
Does he use spoon?