Language
English (US)
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
Feeding Categories
Likes
Dislikes or Avoids
Protein
Dairy
Vegetables
Fruits
Grains
Other
Feeding Skills
Yes
No
Needs Help
Any thoughts?
Does your child feed himself?
Does he use fingers?
Does he use fork?
Does he use spoon?
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
Does your child have pain or complain of pain regularly?
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
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
SENSORY PROCESSING
Does your child register information?
Child does not move around or explore environment
Difficulty understanding non-verbal cues
Dislikes noisy items such as vacuum, lawn mower
Disorganized - lacks purpose in activity
Easily distracted from task by external stimuli
Easily frustrated
Excessive pressure demonstrated during activities
Excessively messy room
Fixates or perseverates
Generalized delayed processing
Hypersensitive to movement - motion sickness
Hypersensitive to pain
Lacks creative play and exploration
Lacks flexibility / Resistant to change
Loves to spin, swing, jump
Over sensitive to light, Smells, Sounds, Or Tastes
Picky eater
Uncomfortable with open spaces such as a shopping mall
Uncomfortable with playground activitites
Under sensitive to smells / may sniff objects
Under sensitive to taste
Bilateral Integration
Able to catch a ball at midline
Difficulty with reading
Poor balance - trips easily
Reported clumsiness
Tends to use each hand on its own side of the body
Will attempt to turn the paper/book when writing/coloring activity crosses midline
Will not reach across body for object
Will turn body to avoid reaching across midline
Ability to complete a new task as requested (Praxis)
Able to imitate or play games, move body from verbal request (jump up, sit down, i'm going to get you)
Able to assume postures from visual demonstration (jump like me, can you spin in a circle like this)
Seems to be uncoordinated
Child does not move around or explore his environment
Difficulty playing on playground
Tends to run on playground, but not climb or explore equipment
Comments:
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
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