Background Information
Clinical location —Please choose an option— Antelope Valley (Palmdale) Los Angeles San Gabriel Valley (West Covina) Bakersfield
Is your primary language spoken English? Yes No
If English is not your primary language, an interpreter may be provided by your insurance. Would you like an interpreter for your services? Yes No
If yes, please provide language needed
No, I would like to opt out of interpreter services Yes No
Client's Name (required)
Birth Date (required)
Age (required)
Home / Cell Phone Number
Address (required)
Email address (required)
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Referring Information
Who referred the client for an evaluation?
Reason for referral related to occupational therapy?
What are the primary concerns/goals for occupational therapy?
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Medical History
Current prescribed medications:
Known food allergies:
Special Diet (GFCF, Ketogenic, pureed food only, tube feeding, etc.):
Medical precautions:
Diagnosis(es) given by other health care professionals?
Hospitalizations, date and length of stay (estimation is acceptable):
Surgeries?
Currently receiving services from other health care professionals:* Psychologist PT Speech and Language Nutritionist Behavioral Specialist Other:
* - Please note frequency/duration of services (e.g. PT 1x/week for 60 minutes)
Other
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Self-Care Skills
Please check the box that most accurately reflects the amount of assistance needed for the client to complete the following:
Takes off pants: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Puts on pants: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Takes off shirt: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Puts on shirt: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Buttons: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Zippers: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Snaps: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Puts on shoes: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Takes off shoes: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Ties shoes: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Puts on socks: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Takes off socks: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Toileting: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Bathing/Shower: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Toothbrushing: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Spoon Usage: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Fork Usage: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
knife Usage: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
Straw Usage: Independent (no cues, prompts, or assist) Supervision (verbal, visual cues; no physical assist) Minimal assistance (1-25%) Moderate assistance (26-50%) Maximum assistance (51-75%) Total assistance (76%-100%)
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Range of Motion (ROM) / Pain Levels
For the “Pain Level” columns, please write a number between 0-10 (0 = no pain, 10 = max pain).
For the range/motion columns, please check one of the three boxes that most accurately reflects your current range of motion in the following areas:
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Sensory Processing Checklist
The purpose of this sensory processing checklist is to help you become educated/aware about particular signs of sensory processing dysfunction and allows the professional to gather a background of behavior responses. It is not to be used as a diagnostic criteria for labeling any sensory processing disorder; but rather, as an educational tool and checklist for knowledge. Please check symptoms that you feel best describe your current sensory behaviors/patterns.
Tactile Sense: input from the skin receptors about touch, pressure, temperature, pain, and movement of the hairs on the skin.
Proprioceptive Sense: input from the muscles and joints about body position, weight, pressure, stretch, movement, and changes in position in space.
1) Please note any loss of or lowered sensitivity (touch, pressure, temperature, pain) in the parts of your body. This can be anywhere along from the top of your head to the tip of your toes.
2) Please note any hypersensitivity (more than usual; touch, pressure, temperature, pain) in the parts of your body. This can be anywhere along from the top of your head to the tip of your toes.
3) Please note any particular heaviness or weightedness in the parts of your body. This can be anywhere along from the top of your head to the tip of your toes.
Vestibular Sense: The vestibular system is the sensory system that responds to motion or change of head position. The receptors for movement are located in the inner ear. They tell the brain what direction the head is moving, the speed of the movement and where we are in space.
1) Please note any changes in blood pressure, headaches, light-headedness, etc. Please note any details as to when it happens (e.g. when getting up too quickly, when waking up, throughout the day, after mealtimes, etc.).
Other Senses: There are also sensory processing skills related to the visual (sight), auditory (sounds), oral (mouth, taste), olfactory (smell), and interoceptive (inner control, such as bladder & bowel, self-regulation).
1) Please note any changes in any visual, auditory, oral, or olfactory senses as compared to how it was prior to incident
2) Please note any changes in any interoceptive senses, including bladder control, bowel control, self-regulation (e.g. frustration tolerance), and other possible changes (e.g. sweating more, high heart rate, high blood pressure).
If there is any other information that you would like to provide that has not yet been targeted, please let us know below:
Optional: If you would like to provide any documents such as diagnostic evaluations, IEP's and/or other evaluations, please upload here.
Today's Date (required)
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I love bringing my little one here. I've notice such a big difference in her speech. And Ms.Rachel is amazing... read more 
