Fundamental Therapy Solutions
OKLAHOMA New Patient Intake Form

Authorization of Daily Living

Family History

Are there any cultural or religious beliefs you would like us to be aware of?

Does anyone in the family have a history of Speech, Language, Hearing, Balance, Reading, or Mobility problems? If yes, please explain.

Prenatal, Birth & Neonatal History

Were there any problems during pregnancy? If yes, please describe.

Child's Birth Weight (___ lbs. ___oz.)

Delivery

Vaginal

C-Section

Was your child born prematurely? If yes, please answer the next question as well.

Yes

Child's gestational age (i.e. 34 weeks)

Describe any difficulties at the time of birth

Was there a prolonged hospital stay after birth? If yes, please describe WHY and HOWLONG.

What feeding method was used after birth?

Were there any feeding difficulties? If yes, please describe.

Yes

Fed self

Dressed self

Toilet trained

Tie shoes

Began babbling

First words

Combined words

Grasp crayon/pencil

Rolled over

Medical History

Please list any medical diagnoses your child has along with the date of the diagnosis(e.g. ADHD, OCD, Seizures, Asthma, Autism).

Please list any medication your child takes regularly

Does your child have any allergies (food, latex, etc.) If yes, please explain.

Has your child ever had prolonged problems with (Select all that apply): Thumb

My child has had several ear infections.

Yes

My child has had at least one ear infection which lasted more than 3 months.

Yes

I suspect my child has a hearing problem.

yes

My child has had tubes in his/her ears? If yes, please refer to next question as well.

Yes

Does your child require the use of any special equipment (e.g. Wheelchair, Leg braces)? If yes, please specify.

Please list any surgical history along with the date of surgery (e.g. Tonsillectomy, Adenoidectomy, etc).

Current grade

Type of classroom

Does your child currently have an Individualized Education Plan (IEP)?