Patient History Form

Child's Full Name*

First

Last

Child's Date of Birth*

Child's Age*

Child's Gender Identity and/or Preferred Pronoun*

Child lives with (both parents, mom, dad, grandparents, etc.):*

What is the custody situation?*

Parent(s)/Guardian(s):*

Cell Phone:*

Home Phone

Work Phone

Mailing Address (Street, City, State, Zip)*

Email*

Legal Guardian through DHS? Please include case worker name, contact, and Medicaid ID.

Emergency Contact Name*

Emergency Contact Phone Number*

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Insurance Information >

Primary Insurance Provider*

Policy Holder Name and DOB*

Primary Member ID*

Group ID or Group Name*

SSN

Insurance Provider Phone

Send Claims To:

Street Address City State / Province / Region Postal / Zip Code Country

Secondary Insurance Provider

Secondary Policy Holder Name and DOB

Secondary Member ID

Secondary Group ID or Group Name

Secondary Insurance Provider Phone

Send Secondary Claims To:

Street Address City State / Province / Region Postal / Zip Code Country

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School Information >

Child's School*

Grade

Phone Number

Teacher

Is your child receiving any school accommodations?*

Does your child receive any services at school?*

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Medical and Developmental History >

What is the reason for seeking occupational therapy evaluation or services? *

What are your child’s strengths? What does your child enjoy doing? *

What is your primary concern for your child at this time? What tasks are difficult for your child to perform?*

What would you like to be easier for your child and/or your family? *

Do you have concerns regarding school? Does your child’s teacher(s) have any concerns? If yes, please specify.

Describe your child’s preferred activities and/or toys. What does your child do with preferred toys?*

Does your child enjoy playing with peers or siblings, prefer solitary play, or prefer adult interaction?*

What would you like to learn from our evaluation? *

What is your preferred learning style/How do you learn best? (i.e. visual learner, auditory learner, etc.) *

Please provide us with any other information that you feel is important for us to know about your child:*

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Attachments

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Patient History Form – Child

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