Occupational Therapy Questionnaire

Occupational Therapy Questionnaire

General Information

Client Name(Required)
Date of Birth(Required)
What are your primary concerns for your child?(Required)
Has your child had Birth to Three occupational therapy in the past?
Has your child had outpatient occupational therapy in the past?
If yes,
where
when
 
Has your child had occupational therapy in the hospital (inpatient) in the past?
If yes,
What hospital
When
 
Is your child currently receiving or historically received any of the following services?
If yes, add a line for each location
Where
When
What was treated
 
At what age did your child:
Roll over
Sit up independently
Crawl
Pull to stand
Walk
Does your child receive occupational therapy services as part of their educational plan?

Daily Living Skills

Fill out the following information for your child
My child does the following dressing on their own
My child does the following fasteners on their own
My child does the following on their own
My child does the following feeding on their own
Check the following that apply to your child

Responsible Party Information (Client or Parent/Guardian)

Name(Required)
Name(Required)