Welcome to Pediatric Occupational Therapy
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- Phoebe Osborne
- 5 years ago
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1 Occupational Therapy General Intake Form 5/ Welcome to Pediatric Occupational Therapy Please fill out this form as thoroughly as possible. Should you have any questions or do not understand a statement please skip it and let your therapist know so that she may provide clarification. Child s Name: Today s Date: Your Name: Relationship to the child: Insurance: Medicare Medicaid I am receiving Home Health Care currently CCCW No insurance Coverage Other (Please list) Personal Info.: Has your child ever been to Occupational Therapy before? Does your child have allergies to any of the following: Latex adhesives Other Does your child use prescription medications? Please list what the name is and what it is for: Has your child recently had an EMG, X-ray, MRI or CT scan due to your current condition?
2 Occupational Therapy General Intake Form 5/ Please help us to understand how your child s condition is affecting his or her day to day function. 1. Please list below any tasks that your child is having difficulty doing/performing because of his/her injury/diagnosis. 2. Circle the level of assistance your child needs to complete these tasks. 3. Circle the level of pain your child is having, on a scale of 0-10 with this task. If there is no pain, please circle 0. Tasks Please write the kind of task that your child having difficulty with. A sample is provided Sample: Assistance Please circle the level of assistance Your child needs to complete a specific task. Pain Please circle the level of pain you are having with this specific task 0=no pain 5=need pain meds 10=severe pain Putting on shoes None minimal moderate maximal Dependent % 25% 50 % 75% 90% -100% Functional skills (eating, bathing, dressing, toileting) Mobility Tasks (transfers on and off items, walking, steps) Social Function (attention, play, time orientation, safety) Is your goal (for your child )after therapy to have improved ability? Reduced pain? Non Applicable Which area is affected the most in you re your child s life? (Choose one) Functional skills, mobility skills, Social skills other: To what degree do you feel your child is limited now? (Choose one) 0%, 1-20%, 21-40%, 41-60%, 61-80%, 81-99%, 100%. Please estimate: your child s expected limitation at discharge: (Choose one) 0%, 1-20%, 21-40%, 41-60%, 61-80%, 81-99%, 100%.
3 Occupational Therapy General Intake Form 5/ To Our Clients: The Rehab Department at Rusk County Memorial Hospital has the following policies in place: Rehab Policy #1 It is your responsibility to check with your insurance company regarding therapy related coverage. Rehab Policy #2 Therapy not covered by your child s insurance company is your responsibility. Rehab Policy #3 You must notify the therapist/receptionist of any changes in your child s insurance while receiving therapy services. o Some insurance companies require prior authorization before treatment Rehab Policy #4 Three appointments of: no-show s or cancellation s received less than 24 hours in advance will result in your discharge from therapy. I have read and understand the above Rehab Policies. Participation Policy: The OT staff will give 100% effort to offer you all the resources possible for facilitating improvement in your condition. It is our hope that you give the same effort through treatment participation and completion of programs and exercises recommended for you at home. Lack of home program participation on a routine basis and thus lack of measured improvement in the clinic may constitute discharge from therapy services. I have read and understand the above occupational therapy Participation Policy. Guardian/Parent s Signature Therapist Signature / / Date / / Date
4 Occupational Therapy General Intake Form 5/ Please check the items (yes or no) that best describe your child. After each item and category, please write any remarks or comments that you feel may be helpful. Please do include your child s strengths. Before Birth 1. Were there any illnesses, injuries, fainting spells, bleeding, anemia, operations or any other difficulties? 2. Were any drugs or medications taken during pregnancy? Please specify.. Delivery 3. Was the pregnancy a full term/normal delivery? If not, specify breech, cesarean, etc.. 4. Was the labor normal? If not, please indicate prolonged, short, etc.. 5. Were forceps used? 6. Was medication given during delivery? Specify:. 7. Was your child considered to be a low birth weight? Specify:. 8. Were there complications? If so, please check: Cyanosis Jaundice Congenital defects Limpness 9. Was there need for: Oxygen Transfusions Tube Feeding Neonatal Intensive Care Unit Stay 10. Was the child bottle fed? Breast Fed? Both Other. 11. Did the child have sucking or feeding problems? If so please indicate. Medical History 12. Is your child up to date with immunizations? If not, why?. 13. Has your child had a recent eye evaluation? When? Results. 14. Has your child had a recent hearing evaluation? When? Results. Developmental History 15. When did your child roll over both ways? How many months old? 16. When did your child sit unsupported? How many months old? 17. When did your child crawl on his or her tummy (army crawl)?
5 Occupational Therapy General Intake Form 5/ When did your child crawl on the floor (on hands and knees)? 19. When did your child start walking independently?
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