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 crawlSit independentlyCrawl on hands and kneesWalkBegin solid foodsFirst words How would you describe your child’s motor development?Gross motor (running, jumping, ball play)AdvancedNormalSlowFine motor (beading, lacing, cutting)AdvancedNormalSlowHandwriting/coloring skillsAdvancedNormalSlowGeneral coordinationAdvancedNormalSlowGeneral balanceAdvancedNormalSlowAny comments on your child's motor development? Self-Care SkillsCan your child:Eat independently?YesSometimesNoUse utensils effectively?YesSometimesNoDrink from an open cup?YesSometimesNoTolerate different textures?YesSometimesNoSit for the duration of the meal?YesSometimesNoDressing/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 belowEmailThis field is for validation purposes and should be left unchanged.
