PEDIATRIC THERAPIES at COOL SPRINGS
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PEDIATRIC THERAPIES at COOL SPRINGS Phone: 615-377-1623 1880B General George Patton Drive Suite 202 Franklin, TN 37067 Fax: 615-377-1625 NEW CLIENT FORM Today’s Date: _____________________ Child’s Name: ________________________________________ Birth Date: _______________________ Person Completing Form: ______________________________ Relationship to Child: _______________ Pediatrician: _____________________________ Referring Physician: ____________________________ What prompted this evaluation? Please list specific concerns (i.e. motor, sensory, behavior, language): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Are there other areas of development that are of concern to you? ______________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Current diagnoses: _____________________________________________________________________ _____________________________________________________________________________________ Family History: Lives with both parents: Yes _____ No _____ If no, describe: _______________ _____________________________________________________________________________________ Siblings (names, ages, any history of delays): ________________________________________________ _____________________________________________________________________________________ Birth History: Is this child: Biological child _____ Adopted child _____ Please indicate: Length of pregnancy: __________ Birth weight: __________ Notable circumstances during pregnancy, labor, delivery, and/or following birth: ___________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Medical History: Please circle any of the following illnesses that are common conditions in your child or which your child has acquired. List approximate ages in the space provided. Allergies _______ Asthma _______ Chicken Pox _______ Colds _______ Croup _______ Ear Infections _______ Headaches _______ High Fever _______ Measles _______ Pneumonia _______ Seizures _______ Sinusitis _______ Tonsillitis/Adenoids _______ Other __________________________________________________ Pediatric Therapies 3-14 1 New Client Form Has your child had a vision test/screening? Yes No Date: _______________ Results: ______________________________________________________________________________ Has your child had a hearing test/screening? Yes No Date: _______________ Results: ______________________________________________________________________________ Significant illnesses: ____________________________________________________________________ _____________________________________________________________________________________ Specialists/Physicians seen (include dates, names, specialty): ___________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Special Tests (X-rays, MRIs, etc.) including dates: _____________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Hospitalizations/Surgeries including dates: __________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Precautions: __________________________________________________________________________ _____________________________________________________________________________________ Medications your child is taking and for what condition: _______________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Developmental History: Please indicate at what age your child achieved the following developmental milestones: Sitting: ________ Crawling: ________ Standing: ________ Walking: ________ Babbling: ________ Single words: ________ Combining words: ________ Toilet training: ________ Describe overall coordination: ____________________________________________________________ _____________________________________________________________________________________ Are there currently or have there been any feeding problems (i.e. sucking, swallowing, drooling, chewing, extreme picky eating, etc.)? Please explain: _________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Describe your child’s current vocabulary: ___________________________________________________ _____________________________________________________________________________________ 2 Pediatric Therapies 3-14 New Client Form How many words is he/she using? 1000’s_____ 100s_____ 50–100_____ 25–50_____ 10-25_____ 10 or less_____ none_____ If non-verbal, how does he/she communicate? ______________________________________________ _____________________________________________________________________________________ Describe social language abilities: _________________________________________________________ _____________________________________________________________________________________ Educational History: School: _________________________________________ Grade: _____________ Please indicate your child’s school schedule (i.e. days, times, etc.): ______________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ List your child’s teacher or other appropriate contact person and phone number: __________________ _____________________________________________________________________________________ Describe your child’s school performance: __________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What if any special services does your child receive at school? __________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Previous Assessments and Therapies: Please list any other evaluations, including dates that your child has undergone or has pending (i.e. OT, PT, Speech and Language, Psychoeducational, etc.). List contact names and phone numbers. OT: __________________________________________________________________________________ PT: __________________________________________________________________________________ SLT: _________________________________________________________________________________ Other: _______________________________________________________________________________ _____________________________________________________________________________________ Please list any developmental therapies or interventions your child has participated in or is currently participating in (i.e. OT, PT, SLT, Music Therapy, counseling, etc.). Include dates: ___________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Social Information: Personality characteristics: ______________________________________________________________ _____________________________________________________________________________________ 3 Pediatric Therapies 3-14 New Client Form Interests/hobbies: _____________________________________________________________________ _____________________________________________________________________________________ Describe peer relations: _________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Describe your child’s most concerning/challenging behaviors: __________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Additional Comments: My child’s strengths are: ________________________________________________________________ _____________________________________________________________________________________ My child’s greatest challenges are: ________________________________________________________ _____________________________________________________________________________________ My child’s fears are: ____________________________________________________________________ _____________________________________________________________________________________ What works to motivate or reward your child? ______________________________________________ _____________________________________________________________________________________ What are the most important skills you hope for your child to improve upon or develop? ____________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ What other information would you like for us to know about your child? _________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ ____________________________________________________ Signature 4 _______________________________ Date Pediatric Therapies 3-14
