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(256) 517-9277
OWENS CROSS ROADS
(256) 542-1970
MADISON
(251) 200-4750
GULF SHORES
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About Us
Meet the Owner
Meet the Team
Locations
Owens Cross Roads
Madison
Gulf Shores
Careers
Services
Speech Therapy
Occupational Therapy
Physical Therapy
Feeding Therapy
For Pediatricians
Testimonials
Resources
Getting Started
Forms for Parents
FAQ
Blog
Contact
Home
About Us
Meet the Owner
Meet the Team
Locations
Owens Cross Roads
Madison
Gulf Shores
Careers
Services
Speech Therapy
Occupational Therapy
Physical Therapy
Feeding Therapy
For Pediatricians
Testimonials
Resources
Getting Started
Forms for Parents
FAQ
Blog
Contact
NEW PATIENT FORM
Child's name
Person Completing Form
Relationship to Child
Description of the problem(s) that brought you to The SpOT Clinic. Why do you or your physician feel that your child needs OT, PT, or speech services?
Has your child had any surgeries?
Yes
No
Describe any surgeries (what type and when, e.g., tubes, tonsillectomy, etc), major accidents, or hospitalizations.
Did your child receive early Physical Therapy intervention services?
Yes
No
Unsure
Did your child receive early Occupational Therapy intervention services?
Yes
No
Unsure
Did your child receive early Speech Therapy intervention services?
Yes
No
Unsure
Explain any previous speech, occupational or physical therapy that your child received. Who? When? What did they address? How was his/her progress?
Explain any other previous relevant therapy that your child received. Who? When? What did they address? Progress?
What information do you hope to gain from the evaluations at The SpOT Clinic?
Please check any of the following conditions that your child has been diagnosed with, if applicable:
Ear infections
Autism
Sinusitis
Tonsilitis
Headaches
Frequent colds
Snoring
Asthma
ADD/ADHD
High fever
Influenza
Covid 19
Other
None of them above
List any medications your child is currently taking.
If your child has a history of seizures, please explain.
Please list any allergies your child has and the reaction to the allergen.
Any dietary modifications? If yes, please explain.
Hearing aid or cochlear implant?
Yes
No
Glasses?
Yes
No
Has your child had a recent vision screening? If so, where?
Vision screening results?
Passed
Failed
Has your child had a recent hearing screening?
Yes
No
If so, where?
Hearing screening results?
Passed
Failed
Please provide the approximate age at which your child began to do the following activities: Sitting
Crawling
Walking
Feeding self (finger foods)
Feeding with spoon/fork
Grasping crayon/marker
Using single words
Conversation
Does your child have difficult walking, running, or participating in other activities which require small or large muscle coordination?
Yes
No
Maybe
Can he/she swim?
Yes
No
Can he/she climb play equipment?
Yes
No
How does he/she sleep at night?
Good
Adequate
Poor
Inconsistent
Does your child have disciplinary issues?
Yes
No
If your child has disciplinary issues, please explain so that we might be able to help with these.
Does your child have any behaviors that are a danger to him/herself or others? If yes, please explain the behavior and how they are handled at home.
Please list any phobias that your child has.
Do you notice your child walking on his/her "tippy toes?"
Often
Sometimes
Never
How does your child primarily drink?
Bottle
Sippy cup
Cup
Straw
Other
Describe your child's response to sound (e.g., responds to all sounds, tolerates loud noises, responds to loud sounds only, inconsistently responds to sounds, etc).
Is your child sensitive to or does he/she react negatively to certain textures in the mouth or to the touch? If yes, explain.
Did/does your child attend preschool?
Yes
No
If so, where?
If your child is school age, how would you describe his/her handwriting?
Neat
Sloppy
Average
Too large
Too small
Other
Does your child have difficulty transitioning from one activity or environment to another at home?
Yes
No
Maybe
Does your child have difficulty transitioning from one activity or environment to another at school?
Yes
No
Maybe
Does your child have a current IEP? (If so, please provide a copy of the IEP to The SpOT Clinic for continuity of care.)
Yes
No
I'm not sure.
What type of classroom is he/she in? (General Education, Resource, Self-Contained)
Check any that your child currently receives while at school.
Speech Therapy
Occupational Therapy
Physical Therapy
Applied Behavioral Analysis (ABA)
1:1 Aid
Social skills
Other
Please describe any concerns you have about your child's social skills or ability to make/keep friends, if applicable.
How does your child interact with other children?
Send
3639
Home
About Us
Meet The Owner
Meet The Team
Locations
Careers
Services
Speech Therapy
Occupational Therapy
Physical Therapy
Feeding Therapy
For Pediatricians
Testimonials
Resources
Getting Started
Forms for Parents
FAQ
Blog
Contact Us
