post_New_Patient

Kindred Pediatric Therapy New Patient Intake Form
Personal Information
Patient Name
Appointment Date

MonthDayYear
Date
MaleFemale
Patient’s date of birth

MonthDayYear
Date
Mother’s Name:
Can this person drop off/pick up your child?

YesNo
Father’s Name:
Can this person drop off/pick up your child?

YesNo
Diagnosis (if any)
Who referred you to Kindred Pediatrics?
Address

Home Address

Street Address Line 2

CityState

Zip Code
Cell Phone
Work Phone
Email
example@example.com
Emergency Contact 1:
Relation
Phone
Can this person drop off/pick up your child?

YesNo
Emergency Contact 2
Relation
Phone
Can this person drop off/pick up your child?

YesNo
Please list everyone who lives in the patient’s home: (Name/relation/age)
1
2
3
4
5
6
7
8
MEDICAL INFORMATION - PHYSICIAN
Primary Care Physician
Phone
Fax
Please enter a valid phone number.
INSURANCE INFORMATION *Attach copy of front & back of patient's insurance card(s) Please indicate if patient is covered under Primary and/or Secondary insurance coverage
Primary Plan
Insured Name
Policy or ID #
Relationship to insured
Group #
Insured date of birth

MonthDayYear
Date
Secondary Plan
Secondary Insured Name
Policy or ID #
Relationship to insured
Group
Insured date of birth

MonthDayYear
Date
BIRTH HISTORY
Weeks of Gestation
Due Date

MonthDayYear
Date
VaginalCesarean
Birth Weight
Delivering Hospital
Medications taken during pregnancy
Other exposures during pregnancy
Birth History Unknown

AdoptedFoster CareParent unable to reportOther
Complications with pregnancy, delivery, birth
AnoxiaBreech PresentationCardiac AbnormalitiesEclampsiaDrug ExposurePre-eclampsiaOther
Please describe feeding at birth

0/140
Extended Hospitalization?

YesNo
Length of stay
Reason for extended hospitalization
PostNatal Complications
Oxygen

YesNo
Length of Time
Feeding Tube

YesNo
Length of Time
NICU

YesNo
Length of Time
IVH

YesNo
Grade

LeftRight
PATIENT MEDICAL HISTORY
SeizuresHeadachesEar Tube SurgeryEasy BruisingFeeding issuesAbnormal Tone
Hearing ImpairmentDizzinessSleep DisturbancesFrequent Ear InfectionsAsthmaOther
Special Precautions
Allergy Alert

0/100
FAMILY/SOCIAL HISTORY
Vision ImpairmentsIntellectual DisorderPsychiatric DisorderCardiac DiseaseAutismADHDHearing Impairments
Immunodeficiency DisorderRespiratory DiseaseMusculoskeletal DisorderAnxietyLearning DifficultyFinancial DifficultyTransportation Difficulty
Other or comments
MILESTONES

Please indicate the age the child developed this skill (In months)
Crawled
Walked
Finger fed self
Babbled
Dressed Self
Rolled from stomach to back
Fed self with utensils
Sat un-supported
Used two-wordcombinations
Used Sentences
Said First Word
Slept all night
Toilet trained
Pulled to stand
Drank from cup
AUDIOLOGY
Has your child’s hearing been tested?

YesNo
Date Tested

MonthDayYear
Date
Results

NormalAbnormal
Comments
SURGERIES & HOSPITALIZATIONS
Has your child been hospitalized?

YesNo
Has your child had any surgeries?

YesNo
If yes, please provide the following information:
1. Date

MonthDayYear
Date
Age
Hospital
Reason
2. Date

MonthDayYear
Date
Age
Hospital
Reason
3. Date

MonthDayYear
Date
Age
Hospital
Reason
4. Date

MonthDayYear
Date
Age
Hospital
Reason
5. Date

MonthDayYear
Date
Age
Hospital
Reason
SURGERIES & HOSPITALIZATIONS
Does your child take medication?

YesNo
(Please list ALL medications your child is currently taking.)
1. Medication
Purpose
Dosage
Prescribing Doctor
2. Medication
Purpose
Dosage
Prescribing Doctor
3. Medication
Purpose
Dosage
Prescribing Doctor
4. Medication
Purpose
Dosage
Prescribing Doctor
TREATMENT HISTORY
Speech: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
Occupational: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
Physical: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
Behavioral/Counseling: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
Cardiologist: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
Audiologist: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
Neurologist: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
Gastroenterologist: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
Other: Begin Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Location/Doctor/Therapist:
EDUCATIONAL HISTORY
Does your child attend school?

YesNo
If yes, where do they attend?
What type of classroom are they in?

TraditionalInclusiveResourceSelf Contained with ratio:
Ratio
What is their teachers name?
If no, where does your child stay during the day?
PARENT/CAREGIVER FEEDBACK & CONCERNS

(Please check ALL boxes that identify an area where you have concerns about your child:
Activities of daily livingAnxietyAttention SpanBehaviorCommunity ambulationDecreased strengthDelayed developmentFind motor skillsHandwritingIndependence
School performanceLearning DifficultiesMobilityMotivationStiffnessPlaySocializationSensory aversionsSensory seekingSpeech/LanguageFeeding
Other
What are your primary concerns regarding your child?
When did you first notice the reason for your concerns?
How does your child express his/her needs (i.e. ask, point, cry, scream, one word, pull, caregiver toward area, etc.)?
Did your childs doctor express concern? If so please explain
What are your child's strengths?
What are your child's weaknesses?
What are your child's favorite activities (i.e. toys, games, food, etc.)?
What are your goals for therapy?
Is there anything that seems unusually difficult for your child or your family?
Is there a day of the week and/or time that you prefer for appointments if your child qualifies for therapy?
Should be Empty:

Kindred Pediatric Therapy New Patient Intake Form

Personal Information

MEDICAL INFORMATION - PHYSICIAN

BIRTH HISTORY

PATIENT MEDICAL HISTORY

FAMILY/SOCIAL HISTORY

MILESTONES

AUDIOLOGY

SURGERIES & HOSPITALIZATIONS

SURGERIES & HOSPITALIZATIONS

TREATMENT HISTORY

EDUCATIONAL HISTORY

PARENT/CAREGIVER FEEDBACK & CONCERNS