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OT Paediatric Intake Form
0
Paediatric Intake Form
Step
1
of
19
– Child Information
5%
Child’s Full Name & Surname
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Gender
(Required)
Select
Male
Female
Home Address
(Required)
Street Address
Address Line 2
City
ZIP / Postal Code
Postal Address
Same as Home Address
Postal Address
Street Address
Address Line 2
City
ZIP / Postal Code
Home Language(s)
(Required)
Child lives with
(Required)
Contact Number
Parent/Guardian Email Address
(Required)
Parent/Caregiver 1
(Required)
First
Last
Relationship to Child
(Required)
Occupation,
(Required)
Education Level
(Required)
Hand Dominance
(Required)
Select
Right
Left
Parent/Caregiver 2
First
Last
Relationship to Child
Education Level
(Required)
Occupation,
(Required)
Hand Dominance
(Required)
Select
Right
Left
Current School Name
(Required)
School Address
(Required)
Street Address
Address Line 2
City
ZIP / Postal Code
Current Grade/Class
(Required)
Teacher’s Name
(Required)
School Contact Number
(Required)
Previous Schools Attended
Who referred your child for Occupational Therapy?
(Required)
Referring Doctor / Professional
(Required)
Reason for referral
(Required)
Main concerns
(Required)
Motor skills
Handwriting
Attention
Coordination
Emotional reglation
Behaviour
Independence
School performance
Previous Assessments & Therapy
(Required)
Previous Occupational Therapy
Speech Therapy
Physiotherapy
Psychological Assessment
Remedial Support
Other interventions
Complications during pregnancy
(Required)
Yes
No
Medication during pregnancy
(Required)
Yes
No
Baby active/restless during pregnancy
(Required)
Yes
No
Full term pregnancy
(Required)
Yes
No
Gestation period
(Required)
Type of delivery
(Required)
Labour details
Complications during delivery
Birth weight
(Required)
Breathing difficulties
ICU/NICU admission
(Required)
Yes
No
Post Natal & Infant History
(Required)
Feeding difficulties
Sleeping difficulties
Floppiness or stiffness
Breathing difficulties
Frequent illness or infections
Did your child crawl on all fours?
(Required)
Yes
No
Dressing independence
(Required)
What age did they start?
Toileting
(Required)
What age did they start?
Fine motor skills
(Required)
What age did they start?
Current state of health
Allergies
Medication
Seizures
Visual/hearing difficulties
Hospitalisations and specialists
Other
Explain more
(Required)
Behaviour & Emotional Regulation
Attention and concentration
Impulsivity
Emotional regulation
Temper tantrums
Clumsiness
Anxiety/fears
Other
Please describe any concerns you have about your child’s behaviour.
Family structure
(Required)
Siblings
(Required)
Family history of learning or medical difficulties
Relationships with parents, siblings, peers, and teachers
Friendships and group participation
(Required)
Yes
No
School & Learning
Attention and handwriting concerns
Organisation and task completion
Left/right confusion
Letter reversals
Copying difficulties
Select which option describes the child’s difficulty at school.
Activities of Daily Living
Brushing teeth
Bathing
Dressing
Buttons and zips
Shoelaces
Toileting
Eating meals
Homework
Packing school bag
Cleaning up
Please tick all that options that your child is doing independently.
Child strengths
(Required)
Preferred activities
(Required)
Motivators
(Required)
Activities avoided/disliked
(Required)
Additional comments or concerns
(Required)
Medical Aid Name
(Required)
Main Member Name
(Required)
Medical Aid Number
(Required)
Dependant Code
(Required)
POPIA Consent & Permission
Consent for collection and storage of information
Consent for multidisciplinary collaboration
Consent for electronic communication
Confidentiality acknowledgement
Consent
I confirm that the information provided is accurate to the best of my knowledge.
Signature
Email
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