Name
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Child's First Name
Child's Last Name
DOB
*
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Month
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Day
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)
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)
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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