Name
*
Child's First Name
Child's Last Name
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Occupational Therapy Intake and Occupational Profile
What do you see as your child’s strengths?
0/100
In one sentence, how would you describe your child?
0/100
List all concerns that you may have:
0/80
List concerns that arise out of your child’s daily routine: (Including morning routine, school, eating, sleeping, dressing)
0/80
What are our primary goals regarding therapy?
0/85
SCHOOL HISTORY
Hand preference:
Have any grades been repeated?
What does the teacher say about your child?
0/50
How does your child feel about school?
0/85
Do you have concerns about your child’s participation or performance at school?
Yes
No
If Yes, please explain:
0/80
DEVELOPMENTAL HISTORY
Children sometimes act or appear younger than there chronological age. What age do you think best describes your child and why?
0/50
Self-Help: (Check yes/no)
Rows
Yes
No
Put on shirt independently
Button independently
Zips independently
Ties shoes
Snaps independently
Dress self independently
Reaching for objects
Finger Feeding
Using Knife for cutting
Eating with spoon
Drawing a circle
Cutting with scissors
Bathing independently
Combing hair
Toilet trained Bowel
Bladder
Toileting independently
Does your child have difficulty learning new motor skills compared to other children his/her age?? Do you have any examples?
0/130
How well does your child do the following? (Checkyes/no)
Rows
Yes
No
Wake up during the night:
Difficulty falling asleep:
Does your child have a difficult time to wake up in the morning:
Sleep in own bed:
Take naps during the day:
Picky eater:
Avoid certain textures:
Gags at/on foods or utensils:
Avoids food that requires lots of chew:
Independent with toileting:
Following toilet training routine:
Difficulty playing alone:
Difficulty with pretend play:
Difficulty using playground equipment:
Does your child avoid certain types of toys (i.e. textured toys):
Does your child avoid any messy play (i.e. sand, paint, glue, etc):
Difficulty playing with other children:
Describe your child's bedtime routine
0/100
EATING - Explain:
0/100
TOILETING - Explain:
0/80
Duration of play:
1-2 min
5-10 min
more
PLAYING - Explain:
0/100
Does your child exhibit tantrums:
Yes
No
Frequency_______times/day:
Frequency_______times/week:
What triggers the tantrums?
0/100
Duration of tantrum:
What strategies do you use to calm your child during a tantrum?
0/100
What do you do that works the best to obtain cooperation from your child?
0/100
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