New Patient Intake Form | Mighty Kids Therapy

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Street Address
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First Name Last Name

Area Code Phone Number

Street Address
Street Address Line 2
City	State
Zip Code	Country

First Name Last Name

Area Code Phone Number

Street Address
Street Address Line 2
City	State
Zip Code	Country

First Name Last Name

Area Code Phone Number

First Name Last Name

Vaginal Cesarean Section

Please indicate the approximate age (in months) in which your child met the following developmental milestones:

History of reflux Difficulty latching on to breast or bottle Weak suck Excessive drooling Unable to drink from a cup or straw Overstuffs mouth with food Gagging during feeding or with the sight/smell of food Avoids certain tastes/textures Difficulty chewing foods

Difficulty with pronouncing words/sounds Echolalia (repeats words/phrases/quotes) No verbal language Limited vocabulary Difficult to understand your child's speech sounds Stuttering or fluency difficulties History of frequent ear infections History of Pressure Equilizing tubes ("ear tubes")

Easily distracted Difficulty attending to a task to completion Poor impulse control Refusal to obey Difficulty understanding or following simple instructions Doesn't seem to understand social cues Difficulty making and keeping friends Poor social interactions

Weak hands Poor pencil grasp No hand dominance Poor handwriting Difficulty with hand-eye coordination

History of sports related injuries Chronic pain Joint pain

Patient Information

Parent/Guardian Information

Emergency Contact

Insurance Information

Medical History

Areas of Concern