core4therapy_Medical

Patient Information and Medical History
1. Please enter the patient/child's information.
Name

First NameMiddle InitialsLast Name
Date of Birth

MonthDayYear
Gender

FemaleMale
Marital Status

SingleMarriedDomestic PartnerSeparatedDivorcedWidowed
Street Address
Apt./Unit #
City
State
Zip Code
Mobile Phone
Home Phone
Work Phone
Pediatrician Name
Email
example@example.com
Preferred contact method

Mobile PhoneHome PhoneWork PhoneEmail
2. Please upload a copy of the front and back of your primary insurance card to the patient portal or contact the office at (859) 225-5424 for other options for sharing a copy of your insurance cards. The patient portal can be accessed by going to our website www.core4therapy.com and clicking on the patient portal tab. Please choose "I am an existing client" followed by the pink bar stating "never booked online with us before", then follow the prompts for uploading a document. Enter the guardian's phone number and email that is on file with Core4 Therapy and then enter the patient's birthdate.
3. Please upload a copy of the front and back of your secondary insurance card, if applicable, to the patient portal using the instructions above.
4. Siblings
Sibling #1 Name
Sibling #1 Age
Sibling #2 Name
Sibling #2 Age
Sibling #3 Name
Sibling #3 Age
5. Name of the Daycare, Preschool or School your child attends:
Grade
6. Extra-Curricular Activities and Interests:
7. Pregnancy

NormalDifficult
Explain if Difficult:
Delivery

NormalDifficult
Explain if Difficult:
Condition of child at birth:
8. Does your child have allergies? If so, what kind?
Allergy #1
Reaction #1
Allergy #2
Reaction #2
Allergy #3
Reaction #3
9. Does your child have a history of ear infections?
Does your child have ear tubes?
ENT Doctor
Date

MonthDayYear
Has he/she had more than one set?
10. Has your child had a recent hearing evaluation? Results:
11. Has your child had a recent vision examination? Results:
Does your child wear glasses?
12. Has your child had surgery serious illnesses and/or injuries? If so, please explain:
13. Is your child taking any medications? If so, please list them:
Medication #1
Dosage #1
Frequency #1
Reason for talking #1
Medication #2
Dosage #2
Frequency #2
Reason for talking #2
Medication #3
Dosage #3
Frequency #3
Reason for talking #3
14. Does your child have any sleeping difficulties? If so, please describe the sleeping difficulties:
15. Approximate age that your child:
Sat
Crawled
Walked
Babbled
Said first words
Produced simple phrases and sentences
16. What is your concern about your child's communication skills and/or learning abilities?
17. What is your concern about your child's motor skills and/or self-help skills?
18. Do you have concerns about your child's behavior or social interactions?
19. Do you have other concerns regarding your child?
20. Does your child have a diagnosed speech/language disorder, sensory processing disorder, behavioral disorder, motor disorder or any other disorder? What is the diagnosed delay or disorder?
21. Do any other family members have a history of a speech/language disorder motor disorders sensory processing disorder, etc.? If so, please describe:
22. Has your child received previous speech/language therapy, occupational therapy or other services? If so, where did your child receive services? Dates of services:
Where #1
Date #1

MonthDayYear
Where #2
Date #2

MonthDayYear
Where #3
Date #3

MonthDayYear
23. Do you have Evaluation Reports Therapy Reports, Progress Reports, etc. from previous services? Can you provide copies of these?
24. What other services has your child received?
Check all the apply:

OTCounsellingPTSpecial Education InstructionOther
From whom?
25. What do you hope to achieve from speech-language therapy and/or occupational therapy?
26. Do you have any other information you would like us to know regarding your child or family?
My signature indicates that the information provided is accurate to the best of my knowledge.
Signature

Clear
Date

MonthDayYear
Date
Please print your name
Should be Empty:

Patient Information and Medical History

1. Please enter the patient/child's information.

3. Please upload a copy of the front and back of your secondary insurance card, if applicable, to the patient portal using the instructions above.

4. Siblings

8. Does your child have allergies? If so, what kind?

13. Is your child taking any medications? If so, please list them:

15. Approximate age that your child:

22. Has your child received previous speech/language therapy, occupational therapy or other services? If so, where did your child receive services? Dates of services:

24. What other services has your child received?