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Page 1 of 7 304 Judd Place Drive Fuquay Varina, NC 27526 Phone (919)557-8305 Fax (919) 557-8306 Shining Stars Physical Therapy Intake Questionnaire Patient’s Name: ___________________________ Mailing Address: __________________________ __________________________ Home Phone: _____________________________ Cell Phone: _______________________________ Email: ___________________________________ Today’s Date: __________________ Date of Birth: __________________ Grade: ________________________ School: _______________________ Siblings: ______________________ ______________________________ What are your primary concerns and reason for referral? Please consider all areas of development that apply to your child, i.e. academics, self care skills, social relationships, sensory processing, fine and gross motor skills, and play skills. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What are your child’s favorite things to do and play with (i.e. hobbies, sports, toys)? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Has your child received a diagnosis? Yes No Please list any diagnosis. ________________________________________________________ Please list any evaluations your child has had, including place and date. Please attach any relevant assessments. ___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Page 2 of 7 Please indicate if your child has ever been seen by any of the following. Psychologist Name and Address ________________________________________________________ ________________________________________________________________________ Neurologist Name and Address ________________________________________________________ ________________________________________________________________________ Physical Therapist Name and Address ________________________________________________________ ________________________________________________________________________ Speech Therapist Name and Address ________________________________________________________ ________________________________________________________________________ Occupational Therapist Name and Address ________________________________________________________ ________________________________________________________________________ Orthopedic Doctor Name and Address ________________________________________________________ ______________________________________________________________________________ Any other professions Name and Address ________________________________________________________ ______________________________________________________________________________ Developmental and Medical History Please describe your child’s birth history. List any complications during pregnancy, birth, and infancy. _______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Is your child adopted? Yes No. If yes, please describe circumstances surrounding the adoption.______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Page 3 of 7 Looking back at the first two years of your child’s life, what type of baby was he/she (i.e. feeding, sleeping, activity level, temperament)? _______________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Please answer the following: Breastfed Bottle Fed Specific Health Problems Thumb sucker/pacifier (to what age) Feeding problems Sleeping problems Colic or fussy baby Prefers certain positions Dislikes stomach Dislikes back Able to self sooth Mouthed toys Enjoys bouncing Calmed by car rides/infant swing Becomes upset by car rides/swing Toe walker (until what age) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Comments: ____________________ Did your child have any illnesses such as ear infections, tubes, cardiac problems, respiratory problems, fevers, frequent colds, seizures? Please describe. ______________________________________________________________________________ ______________________________________________________________________________ Has your child had any difficulties with diarrhea, constipation, vomiting, headaches, or stomach aches? Please describe. __________________________________________________________ ______________________________________________________________________________ Does your child have any allergies? Please list. _______________________________________ ______________________________________________________________________________ Does your child currently take any medications? Please list and indicate for what conditions. _____________________________________________________________________________________ _____________________________________________________________________________________ Page 4 of 7 Has your child ever used orthotics or any other mobility equipment? If yes, please describe. _____________________________________________________________________________________ _____________________________________________________________________________________ Developmental Milestones Please give approximate ages if remembered, or comment on anything unusual. Rolled Over _______________ Walked ____________________ First words ________________ Sat alone ________________ Chewed solid food ________________ First sentence _________ Crawled _______________________ Drank from a cup ________________________ How long did your child crawl? ________________ Can your child go up and down stairs safely? How? _________________________________________________________________________ Please describe if your child had any difficulties achieving motor milestones. ______________________________________________________________________________ Please describe any developmental challenges your child has faced or continues to face. ______________________________________________________________________________ ______________________________________________________________________________ Visual and Auditory Development Do you have any concerns about your child’s vision? _____________What are they? _________ ______________________________________________________________________________ Has he/she had a vision exam? ___________ When? ___________________________________ Does your child wear glasses? ____________ Does your child do any of the following? Close one eye or “wink” Tilt head to one side Complain of headaches Yes Yes Yes No No No Trip/Fall frequently Have difficulty reading Avoid eye contact Yes Yes Yes No No No Do you have any concerns about your child’s hearing? Please explain. ____________________ _____________________________________________________________________________ Has your child had a hearing test or screening? What were the results? ____________________ Page 5 of 7 Does your child do any of the following: Cover his/her ears Yes No Not respond to call Yes No Avoid/ “fall apart” in noisy environments Confuses similar sounding words Gets easily distracted Yes No Yes Yes No No Gross Motor Development Do you have any concerns about your child’s gross motor? Please explain. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Does your child have a hand preference (right, left, none)? ______________________________ Please check all that apply to your child: Rolls over Holds head up Sits Without Support Plays on Stomach Crawls Runs/Walks Rides a bike Can Skip Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No Jumping Jacks Swims Catches a ball Throws a ball Can stand on one leg Jumps with both feet Kicks a ball Yes Yes Yes Yes Yes Yes Yes No No No No No No No Is your child involved in any sports/physical activities such as soccer, T-ball, baseball, swimming, horseback riding, basketball, gymnastics, etc.?_______________________________________ _____________________________________________________________________________________ _______________________________________________________________________ Social/Emotional Does your child: Enjoy hugs and kisses Attempt to comfort others Prefer to play alone Have frequent tempers How long do they last? Yes Yes Yes Yes Yes No Enjoy interactive play with others No Display wide variety of emotions No No If yes, how many a day? No Is he/she able to calm themselves? Yes Yes No No Yes Yes No No Page 6 of 7 Please describe your child’s typical play skills. Include information such as ages of other children your child tends to play with, types of activities, ability to play with or near another child, ability to share or take turns. _________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe your child’s behavior on outings such as shopping, birthday parties, restaurants, and family vacations. ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Sensory and Motor Development Please check all that apply to your child: My child is overly sensitive to sensory experiences more so than other children his/her age. Auditory Tactile Visual Movement Taste Smell My child does not react to sensory experiences as readily as other children his/her age. Auditory Tactile Visual Movement Taste Smell My child seeks out sensory experiences more so than other children his/her age. Auditory Tactile Visual Movement Taste Smell My child has difficulty differentiating sensory experiences (i.e. confuses sounds, cannot find objects in a drawer or bag without looking, bumps into things, etc.) Please describe: ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ My child has trouble learning new movements. My child tends to be clumsy and has balance and coordination problems. Page 7 of 7 School History Does your child receive special education services? Please include frequency of each (i.e. resources, speech therapy, OT, PT). _________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Is your child able to move around the school independently, tolerate noises in the cafeteria, and attend assemblies, specials, and field trips? _______________________________________ ______________________________________________________________________________ Goals What do you see as your child’s strengths? ___________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ What are your goals for your child? _________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Please feel free to share any additional information you feel would be helpful. ______________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Thank you for your time to help us better understand your child. We look forward to meeting you.