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W W W . F A C E B O O K . C O M / O U T R E A C H P E D I

OUTREACH PEDIATRIC THERAPY, INC.

Date_________________

New Patient Questionnaire

Childs Name: __________________________________________________________________
Primary Diagnosis: ______________________________________________________________
Secondary Diagnosis_____________________________________________________________
Childs Date of Birth: _________________________ Age: ______________________________
Language child is most exposed to: _________________________________________________
Is your child adopted?_________________
If yes, then how long has your child been in your care? __________
Childs physician: __________________________________
What was the date of your childs last doctors visit? __________________________________
Mothers Name _____________________________________ Age: ______________________
Occupation:_________________________ Education:_________________________________
Address: _____________________________________________________________________
City/State: _____________________________________ Zip Code: ____________________
Phone #: __________________Work #: ________________ Alternate #: __________________
Email address: _________________________________________________________________
Fathers Name: ________________________ Age:__________________
Occupation:__________________________ Education:________________________________
Address: ______________________________________________________________________
City/State: _____________________________________ Zip Code: ____________________
Phone #: __________________Work #: ________________ Alternate #: __________________
Email address: _________________________________________________________________
Emergency Contact Name: ______________________________________________________
Relationship to child: ____________________________________
Address: _____________________________________________________________________
Phone #: __________________Work #: ________________ Alternate #: __________________

Social/Family History
Child lives with:
___ Both Parents

___ Mother

Parents are: ___Married

___ Father

____ Divorced

Patients Name: ________________________________________

Other (explain):____________________

____ Separated

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Revised on: 12/22/11

Other Siblings:
Name

Age

Sex

Grade

Special Needs

Has your child experienced any changes/moves/traumas Yes____ No____

If yes, please describe:____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Familial history (fathers or mothers side) of the following:
____ Attention
___ Behavior
_
___ Learning
___ Impulsivity
_
_
___ Following the law
___ Reading
_
_
___ Hearing/Speech
___ Following Directions
_
_
___ Substance/Alcohol use
___ Emotional/psychiatric
_
_
___ Autism/Asperger
___ Other:______________________________________
_
_

Current Concerns
Please describe your main concerns about your childs development:
___________________________________________________________________________________
___________________________________________________________________________________
__
Has your child been evaluated by a specialist (i.e., developmental pediatrician, neurologist, psychiatrist)
Yes_____ No_____
If yes, please list provider, date, and services received: ______________________________________
___________________________________________________________________________________
Has your childs vision been evaluated? Yes______ No_____
If so, where and when__________________________________________________________________
What were the results?__________________________________________________________________
Has your childs hearing been evaluated? Yes_______ No____
If so, where and when? _________________________________________________________________
What were the results?__________________________________________________________________
Did your child pass the Newborn Hearing Screening? Yes_____ No_____
Has your child had ear infections? Yes___ No___
If yes, how many and when was the last infections? _________________________________________

Patients Name: ________________________________________

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Revised on: 12/22/11

Does your child ever complain of pain or fullness in ears? Yes___ No___
If yes describe: ______________________________________________________________________
Has your child had medical/surgical treatment for ears: Yes___ No___
If yes when and for what reason? ________________________________________________________
Have you ever questioned your childs ability to hear normally? Yes_____ No_______
If yes please describe in detail: __________________________________________________________
____________________________________________________________________________________
Have you ever questioned your childs ability to understand or express his/her thoughts clearly?
Yes____ No______
If yes describe in detail:________________________________________________________________
Has your child ever had any difficulties with the following?
Feeding problems
Swallowing/chewing problems
Picky eater
Please list types of foods your child likes: ______________________________________________
________________________________________________________________________________
Please list any foods your child dislikes or avoids: ________________________________________
_________________________________________________________________________________
Indicate any additional concerns:
Attention Span

Eating Habits

Behavior

Weight Gain/Weight Loss

Learning

Sleeping Habits

Emotional/Social Development

Temper

Reasoning Skills

Unusual Fears/Phobias

Gross motor/Coordination skills

Other: _________________________________

Fine Motor Skills (i.e., tying shoes, writing)

Pregnancy/Birth History
Length of pregnancy_______________________
During pregnancy did mother experience any unusual conditions, illnesses, or accidents (i.e. gestational diabetes,
false labor, preeclampsia, etc.?) or was pregnancy considered high risk? Yes_____ No_______
If yes please describe: ____________________________________________________________________

_____________________________________________________________________________________
Birth weight___________ APGAR Score __________ Place of Birth_____________
Birth conditions:
C-Section Delivery

Breech

Forceps

Did any of the following occur?

Lack of Oxygen/Intubation
Patients Name: ________________________________________

Congenital Defects/problems
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Revised on: 12/22/11

Jaundice
Suction or forceps delivery
Scarring/bruising

Placement in NICU
Medication delivered to child
Other: ______________________________________

Development:
Developmental Milestones (please indicate age the following skills were acquired):
_______

Rolling from stomach to back

_______

Smiling/Cooing

_______

Sitting alone without support

_______

Babbling

_______

Crawling

_______

Saying first word

_______

Standing

_______

producing 2-3 word sentences

_______

Walking

_______

completed potty training

_______

Feeding self with spoon

Does your child understand what you say? _______________________________________________

Do you understand what your child says? ________________________________________________
Which hand does your child prefer: ____
In general how would you describe your childs development?
Slow____ Average ____ Above average______

Educational History
Name of your childs school or daycare?___________________________________________________
Grade? __________ Regular classroom setting: Yes_____ No_______
Are there any special educational modifications? Yes_____ No_______
If yes please describe: ____________________________________________________________________
_____________________________________________________________________________________
Does your child receive therapy through the school? _________
What services are provided? _____________________________________________________________
Has an ARD meeting occurred for your child? Yes___ No___
Does your child have a current IEP?
Yes___ No___
Indicate any of the following areas of difficulty
_______

Reading

_______

Poor Organization

_______

difficulty with following directions

_______

Math

_______

Restless

_______

Difficulty with remember information

_______

Spelling

_______

Distractible

_______

Daydreams

_______

Writing

_______

Short attention span

_______

Inability to complete tasks

Patients Name: ________________________________________

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Revised on: 12/22/11

_______

Other: ____________________________________________________________________

Medical History
Indicate all that apply to your child:
High Fevers

Sinusitis

Urinary infections

Chicken Pox

Mumps

Ear infections

Meningitis

Encephalitis

Measles

Tonsillitis

Head Injury

Pneumonia

Allergies

Epilepsy

RSV

Asthma

Seizures

ADHD/ADD

Strep Throat

Skin rashes or eczema

Upper Respiratory Infections

Other: ________________________________

ALLERGIES ____ yes ____no

Please list type of allergy (i.e., seasonal, etc.) __________________________________________
List any medications currently taken:
Medications

Dosage

Reason

Over the Counter medications:________________________________________________

Are your childs immunizations current?
Yes
No
Has your child ever been seriously ill?
Yes
No
If yes, please explain: ____________________________________________________________
_______________________________________________________________________________
Has your child ever been hospitalized?
Yes
No
If yes, please explain: ____________________________________________________________
______________________________________________________________________________
Has your child ever received Early Childhood Intervention?

Yes
No
If yes, please list provider, date, and services received: __________________________________
_______________________________________________________________________________
List any previous therapy services your child has received:
Name of Provider
Patients Name: ________________________________________

Discipline
Page 5 of 6

Frequency of services

Dates of service
Revised on: 12/22/11

(OT/PT/ST)

(1x week, 2x week)

Personality
Which of the following best describes your child?
Cooperative
Attentive
Willing to try new activities
Prefers to play alone
Has separation difficulties
Easily frustrated
Impulsive
Withdrawn
Social with others
Disobedient

Stubborn
Restless
Nervous/shy
Easily distracted/short attention span
Destructive
Aggressive
Demonstrates inappropriate behaviors
Demonstrates self-abusive behaviors
Other: ________________________________

What are your childs favorite toys/activities? _______________________________________________

How do you discipline your child (i.e., timeouts, redirection)? _________________________________
Do you feel that the methods are effective? ________________________________________________
Are there any other behavioral concerns? __________________________________________________
____________________________________________________________________________________
Would you like additional resource information regarding the following?
Behavior
General Development
ARD/IEP Process
Support Groups
Other: ____________________________________________

What are your therapeutic concerns for your child? What would you like your child to
be able to accomplish?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Patients Name: ________________________________________

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Revised on: 12/22/11

____________________________________________________________________________________
Name of person completing this form: ________________________________
Relationship to child: ___________________________

Patients Name: ________________________________________

Page 7 of 6

Date: ___________________________

Revised on: 12/22/11