Evaluation Intake Form: Orthopedic Child’s Name* Birth Date* Month Day Year Preferred Name* Sex* Male Female Parent/Caregiver* Email* Phone Number*Address* Street Address Address Line 2 City State / ProvinceAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Child lives with* Both Parents Mother Father Grandparents My child is in the foster care system My child is in the foster care system Are there any guardianship/custody issues our office should be aware of?* Yes No Please briefly describe* Primary Care Physician* Medical Diagnosis* Primary Concerns/Reason for Referral*Has your child previously received therapy before? Select all that apply. ST OT PT Where were services received and for how long?* Why did your child discontinue receiving services?* Emergency Contact(s)* Phone*Hospital Preference In the event that my child becomes ill or injured while in therapy and guardians/emergency contacts are unable to be reached, I authorize the provision of emergency medical services to my preferred hospital. I give consent for the administration of any treatment deemed necessary by the treating physician. I understand that I will be liable for any costs associated under this consent to treatment.Signature of Parent/Guardian*Date* Month Day Year Reason for today’s visit:Date of injury: Month Day Year Description of Injury:Was imaging (X-ray, MRI) needed following the injury?* Yes No Was casting, bracing or surgery needed?* Yes No Does your child play sports?* Yes No Please list sports played:* MEDICAL HISTORYPlease elaborate if any of the following are checked Hospitalizations Surgeries Medication Seizures Breathing Problems/Asthma Allergies Ear infections Frequent upper respiratory infections GERD Eats well Picky eater Nutrition a concern? Sleeps well? Other Please list all surgeries and dates*SurgeryDate Please list all medications*Name of MedicationWhat addressing?DosageSide Effects Please list allergies* Ear infections-How frequently?* GERD- age diagnosed* GERD- How treated?* GERD- Have symptoms resolved?* Yes No Current Weight?* Current Height?* Please describe your child’s health in generalCommentsEDUCATIONAL INFORMATIONSchool/Educational Program Currently Attending Grade Level Does your child have an IEP? Yes No Special Services ReceivedDoes your child’s teacher express concerns with his or her development or educational performance? Yes No In what areas: (please check all that apply) Motor Skills Social Skills Overly Active Difficulty Calming Down Is sensitive to bright lights Poor attention span Sensitive to Sound Anxious Has trouble making friends Trouble with changes in routine Handwriting Reading Comprehension Sensory Processing/Sensory Regulation Trouble Following Directions Is there anything else that you feel would be beneficial for us to know about your child? Δ