Occupational Therapy Questionnaire Occupational Therapy Questionnaire Today's Date(Required) Month Day Year General InformationClient Name(Required) First Client Name(Required) Last Date of Birth(Required) Month Day Year What are your primary concerns for your child?(Required) Motor Skills Sensory Processing Behavior/Self-Regulation Social Skills Daily Living Skills (dressing, bathing, grooming, feeding, etc.) Has your child had Birth to Three occupational therapy in the past? Yes No If yes, which county? Has your child had outpatient occupational therapy in the past? Yes No If yes,wherewhen Add RemoveWhat was treated? Why were services discontinued? Has your child had occupational therapy in the hospital (inpatient) in the past? Yes No If yes,What hospitalWhen Add RemoveIs your child currently receiving or historically received any of the following services? Physical Therapy Speech Therapy Vision Therapy Psychological Services (Counseling, Day Treatment, Residential Treatment, etc.) ABA Therapy If yes, add a line for each locationWhereWhenWhat was treated Add RemoveAt what age did your child:Roll overSit up independentlyCrawlPull to standWalkDoes your child receive occupational therapy services as part of their educational plan? Yes No If yes, how often? Daily Living SkillsFill out the following information for your childMy child does the following dressing on their own Socks Shoes Undergarments Pants Shirts Comments My child does the following fasteners on their own Buttons Zippers Snaps Shoe laces Comments My child does the following on their own Toothbushing Bathing Hair Grooming Toileting Comments My child does the following feeding on their own Using utensils Using a cup Comments Check the following that apply to your child Avoids being touched Seeks out touch Easily distracted Appears clumsy Craves spinning Seeks swinging Crashes into people/objects Is in constant motion Has frequent meltdowns Has difficulty with transitions (going from activity to activity) Has difficulty with a change in plans or routine Is a picky eater Has a hard time falling asleep at night Responds negatively to loud noises Is picky about clothing Drools or puts objects in their mouth Responsible Party Information (Client or Parent/Guardian)Name(Required) First Name(Required) First Email(Required) Phone(Required)
