Home Staff Our Place Resources Pay Your Bill Contact Us Occupational/Physical Therapy History Form Step 1 of 4 25% Form completed by First Last Email PhoneChild's Name First Last Motor DevelopmentAt what age did your childBelly crawl Sit independently Crawl on hands and knees Walk Begin solid foods First words How would you describe your child’s motor development?Gross motor (running, jumping, ball play) Advanced Normal Slow Fine motor (beading, lacing, cutting) Advanced Normal Slow Handwriting/coloring skills Advanced Normal Slow General coordination Advanced Normal Slow General balance Advanced Normal Slow Any comments on your child's motor development? Self-Care SkillsCan your child:Eat independently? Yes Sometimes No Use utensils effectively? Yes Sometimes No Drink from an open cup? Yes Sometimes No Tolerate different textures? Yes Sometimes No Sit for the duration of the meal? Yes Sometimes No Dressing/GroomingWhich of the following describes your child? Completely dresses self-independently, including snaps and zippers. Usually dresses self, but may need some reminders or help with fasteners Is physically capable of dressing self, but is easily distracted or has difficulty sequencing Can manage basic pull on/pull of clothing Tries to help Frequently resistive Check all that apply.Which of the following describes your child? Independently and thoroughly cares for hair and teeth Independently washes/dries hands Makes efforts at grooming but needs help for thoroughness Tolerates grooming routines Resists grooming Resists baths Resists shampooing Check all that apply. Social/EmotionalPlease describe any difficulties your child may have or had in the following areas: Daycare; Preschool; Kindergarten; Elementary School; Interacting with Peers; Participating in groups; Participating in busy environments (e.g. restaurants, grocery store); Handling unexpected change; Recovering when angry or upsetPlease list three priorities that you have for your child if they receive Occupational/Physical therapy at our clinic.Please write any other comments belowNameThis field is for validation purposes and should be left unchanged.
