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PediOT Intake Form

This pediatric occupational therapy intake form collects information about a child's demographics, family history, birth history, motor skills, self-help skills, social/educational background, and sensory processing. It gathers details on the child's name, age, parents, siblings, medical history, areas of concern, motor milestones, schooling, play preferences, attention, feeding, dressing, hygiene, and sensory behaviors. The form aims to provide therapists an overview of the child's development for an initial evaluation.

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muffy lucas
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191 views4 pages

PediOT Intake Form

This pediatric occupational therapy intake form collects information about a child's demographics, family history, birth history, motor skills, self-help skills, social/educational background, and sensory processing. It gathers details on the child's name, age, parents, siblings, medical history, areas of concern, motor milestones, schooling, play preferences, attention, feeding, dressing, hygiene, and sensory behaviors. The form aims to provide therapists an overview of the child's development for an initial evaluation.

Uploaded by

muffy lucas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PEDIATRIC OCCUPATIONAL THERAPY INTAKE FORM

DEMOGRAPHIC & FAMILY INFORMATION

Child’s Name: Nickname:

Date of Birth: Age: Male Female

Parent’s Name: Mother

Father

Address:

Telephone Number: Cell:

Pediatrician:

Siblings: Date of Birth:

Have any siblings ever received PT, OT, or Speech Therapy?

Yes No

If yes, please explain:

Do any family members have speech, language, hearing, learning, or physical development problems?

Yes No

If yes, please explain:


AREAS OF CONCERN/GOALS

When did you first have concerns about your child?

What made you concerned?

What strategies or techniques have you been trying independently?

What is your primary concern today?

What specific skills would you like your child to achieve in therapy?

BIRTH HISTORY

Normal pregnancy and delivery: Yes No

If no, please describe:

MOTOR DEVELOPMENT

List approximate age at which your child demonstrated the following skills:

Crawled: Sat up:

Started to walk: Walked unassisted:

Any concerns regarding gross motor skills (i.e., walking up/down stairs, running smoothly)?

Yes No

If yes, please explain:

Any concerns regarding fine motor skills (i.e., stacking blocks, drawing, cutting, writing)?

Yes No

If yes, please explain:


SOCIAL/EDUCATIONAL

Child’s School Grade/Level

If not school age, other group experience?

How does your child play?

prefers to play alone

prefers to play with 1 or 2 others

plays mostly with siblings

plays mostly with adults

has a lot of friends

Is your child able to pay attention as well as most other children his/her age?

Yes No

SELF-HELP SKILLS

Any concerns regarding feeding and eating skills (i.e., using spoon/fork, drinking through straw, food
choices, ability to chew/swallow)?

Yes No

If yes, explain

Any concerns about food choices (i.e., selective eater, eats only certain foods or textures)?

Yes No

If yes, please explain:

Any concerns regarding dressing skills (i.e., getting dressed/undressed, managing buttons/snaps/zippers,
shoe tying)?

Yes No

If yes, explain

Any concerns regarding hygiene skills (i.e. tooth brushing, bathing, combing hair)?

Yes No

If yes, explain
SENSORY MOTOR SKILLS

Please check any statements that describe your child


Frequently trips on his/her own feet
Walks on his/her toes
Frequently bumps into furniture, walls, or other people
Unaware of being touched or bumped unless done with extreme force
Unaware of that face or hands are dirty (i.e., nose running, food on face)
Seems unsure of how to move his/her body; is clumsy and awkward
Slumps or slouches when sitting; places head on hand when sitting
Has difficulty learning new motor tasks
Is in constant motion
Has difficulty sitting still
Chews on pens, straws, shirts, etc
Frequently touches people and objects
Frequently gets in everyone else’s space
Is overly sensitive to touch, noise, smells, etc
Avoids touching certain textures (please list: )
Avoids messy play (i.e., finger paints, playdough, mud, sand)
Only eats certain foods or food textures (please list: )
Is sensitive to clothing tags or textures
Complains about having hair brushed
Resists having teeth brushed
Does not like to have fingernails trimmed
Refuses to walk barefoot
Has trouble falling asleep or staying asleep
Gets “stuck” on toy or task and has difficulty changing to another task
Is fearful on swings
Is fearful of slide or other playground structures
Is fearless on playground equipment
Comments:

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