About
- Background
- Approach
Services
Forms
Contact

Alexandra Buwalda DPT, PCS

About
- Background
- Approach
Services
Forms
Contact

New Client Intake Form (18+ months)

New Client Intake Form (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

Email *

Phone *

(###)

###

####

Referring physician

PCP (if different)

Specialists (Name and specialty)

Family Information

Language(s) spoken in home *

Names and ages of siblings

Parents'/Guardians' main concern *

Medical History

Were there any complications during pregnancy? *

Were there any complications during birth? *

What was your child's birth weight? *

How would you describe early infancy? (sleeping, feeding, etc)

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

Please describe your child's current health *

Is your child vaccinated following CDC guidelines? *

Yes

No

If not, please explain *

Motor milestones (if applicable). At approximately what age did your child:

Roll independently

Sit independently

Commando crawl

Crawl reciprocally

Pull up to stand

Stand independently

Walk independently

Communication

At what age did your child use words (beyond mama, dada)?

At what age did your child use sentences?

If your child is non-verbal, how does he/she communicate?

How would you describe your child’s gross motor functioning in their environment ? (indoors, outdoors, playground, school, etc)

Do you have any concerns about child’s sensory processing (i.e. sensitivity to loud noises, touch, taste, smell, or is your child toe walking)?

Do you have any concerns about your child’s fine motor skills?

Do you have any concerns about your child’s social and emotional development?

Hand dominance

Right

Left

Not sure

Equipment/orthoses

Did/does your child receive any other services? (Early Intervention, PT, OT, SP, Special instruction, play therapy, etc.)

Is your child currently enrolled in daycare/pre-school/school? Please list:

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

Relationship to patient *

Thank you for your submission of the intake form.

Please click one of the links below to review and electronically sign the additionally required forms (Consent to Treat, HIPAA Privacy, Cancellation Policy, Communication Policy and either Consent to Treat at Home or Consent to Treat in a Facility).

CONTACT

Alexandra Buwalda, DPT

@ The Gowanus Treehouse
540 President Street, Suite 1E
Brooklyn, NY 11215

Email: alex@alexbuwalda.com
Phone: 917.648.8682
Fax: 718.858.1188