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Alexandra Buwalda DPT, PCS
About
Background
Approach
Services
Services
Referrals
Testimonials
Forms
Contact
Client Intake Form (0 - 18 months)
Client Intake Form (6 - 18 months)
*Required fields are noted with an asterisk.
Patient Name
*
First Name
Last Name
Sex
*
Female
Male
Age/Date of Birth
*
Parents'/Guardians' Names
*
Address
*
Referring physician
*
PCP (if different)
Specialists (Name and specialty)
Family Information
Language spoken in home
*
Names and ages of siblings
Parents'/Guardians' main concern
*
Child's current health
*
Medical History
Were there any complications during pregnancy?
*
Were there any complications during birth?
*
What was your child's birth weight?
*
Did/does your child suffer from any of the following:
Chronic ear infections
Ear tubes
Childhood illnesses (measles, mumps, chicken pox)
Frequent strep throat
Tonsillectomy/adenoidectomy
Seizures
Restrictive diet
Hearing problems
Vision problems
Please list any ER visits and/or overnight hospitalizations
Please list any surgeries
Please list any previous injuries
Please list any prescription medications *
Please list any allergies *
Other
Motor milestones : select the approximate age your child performed each of the following *
Roll independently
*
Sit independently
*
Commando crawl
*
Crawl reciprocally
*
Pull up to stand
*
Stand independently
*
Walk independently
*
Communication
How does your baby indicate what he/she wants?
*
Does your baby babble or vocalize?
*
Other information
How are your baby's sleeping habits?
*
How are your baby's feeding habits?
*
Do you have any concerns about your baby's self-regulation skills?
*
Please list any other information you would like me to know.
I certify that this information is true and correct to the best of my knowledge. I will notify my therapist of any changes in the above information within 30 days.
Name
*
Date
*
MM
DD
YYYY
Thank you!