OCCUPATIONAL THERAPY BRIEF ADMISSIONS FORM

Child Information and Services

Services Requested

OT

Feeding

Child’s Name

Goes By

DOB

Please enter a date that isn't in the future.

Gender

Male

Female

Diagnosis

Primary concerns for your child to be addressed in the OT evaluation:

Therapy Services and Education

Current therapy services your child is receiving:

Past OT services your child has received and approximate dates:

What grade and school are your child currently in?

Does your child have an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP)?

Has your child had a psychological or neuropsychological evaluation completed?

Medical History

What medications/supplements, if any, is your child presently taking? (Please indicate dosage and reason for the medication)?

Allergies: (list)

No known allergies

Hearing Test

Date Last tested

Please enter a date that isn't in the future.

Results

Never tested

No concerns

Have concerns

Vision Test

Date Last tested

Please enter a date that isn't in the future.

Results

Never tested

No concerns

Have concerns

Current Specialist’s (neurology, orthopedics, cardiology, physiatrist, psychologist etc).

Any major health events in your child’s life/relevant medical history (ie. surgeries, procedures, additional diagnosis)?

Contraindications/Precautions

None

Insulin Pump

G tube

Baclofen Pump

Vagal Nerve Stimulator

Seizure Condition

shunt

Other

Mobility, Communication and Play

Mobility and Equipment

How does your child get around the house?

Does your child use any specialized equipment (hearing aids, eyeglasses, wheelchair, foot orthotics)?

Communication

How does your child best communicate? Verbal (single words, phrases, sentences) or non-verbal (body language, facial expressions, pointing/gestures, AAC device, sign language)?

Play and Hand Use

Favorite toys/play activities:

Is your child

Right handed

Left handed

Neither

Both

Motor Skills and Sensory Processing

Does your child have fine motor difficulties (in use of markers, pencil, fasteners on clothing, feeding utensils)?

Do you have any concerns regarding your child’s sensory processing/regulation (touch, sights, sounds, body awareness, balance, social participation)? If so, please explain.

Self-Care and Activities

How does your child do with self-care activities? Any assistance needed?

Feeding:

Dressing:

Bathing:

Hygiene/grooming (hair care/toothbrushing):

Toileting:

Is your child involved in any extracurricular activities, and what are they?

Parent Signature

Thank you for this information related to your concerns as they relate to occupational therapy. This allows your evaluating therapist to select the most appropriate assessment tool(s) for your child.

Parent Signature

Date