Background Information and Occupational Intake – Adult

Background Information

Clinical location

Is your primary language spoken English?
YesNo

If English is not your primary language, an interpreter may be provided by your insurance. Would you like an interpreter for your services?
YesNo

If yes, please provide language needed

No, I would like to opt out of interpreter services
YesNo

Client's Name (required)

Birth Date (required)

Age (required)

Home / Cell Phone Number

Address (required)

Email address (required)

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?

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:*
PsychologistPTSpeech and LanguageNutritionistBehavioral SpecialistOther:

* - Please note frequency/duration of services (e.g. PT 1x/week for 60 minutes)

Other

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)

					We LOVE DV Therapy Palmdale! My son has Autism and gets Speech. He was getting Occupational Therapy services and has since graduated with the help of Ms.Alyah! Ever since he started there has been a HUGE improvement in his speech and fine motor skills. My child loves going to his therapies here and gets excited when he sees his therapists! It’s such a nice feeling knowing he likes the people there and wants to go back week after week. The staff here are very professional and you can see that they really care about your child. Ms.Amber is great and really takes in mind what my child interests are and turns it into speech opportunities! We are so grateful for all the amazing support from DV Therapy Palmdale!
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Nicholas V.
2 months ago
					Dv therapy is amazing. Staff is wonderful and so helpful. My little has been going for 2 years and has shown so much progress. Thank you to the wonderful ladies working with him.
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Reanna S.
2 months ago
					My kiddo started here when she was a little over two years old. Bronti and Hava have helped her developed her speech in just a matter of months and my daughter continues to expand her vocaulary daily.
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Sabrina L.
3 months ago

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BodyPart & Movement	Pain Level – at rest (0-10) 0 = no pain 10 = max pain	Pain Level – at max range (0-10) 0 = no pain 10 = max pain	Range/Motion
Neck - looking left and right			Typical Range/MotionLimited Range/MotionNo Range/Motion
Neck - looking up and down			Typical Range/MotionLimited Range/MotionNo Range/Motion
Neck - tilting head to touch shoulder			Typical Range/MotionLimited Range/MotionNo Range/Motion
Shoulder – lifting arm straight in front, up towards ceiling			Typical Range/MotionLimited Range/MotionNo Range/Motion
Shoulder – lifting arm to the side (like a butterfly), up towards ceiling			Typical Range/MotionLimited Range/MotionNo Range/Motion
Elbow – bending			Typical Range/MotionLimited Range/MotionNo Range/Motion
Forearm – turning to palm up			Typical Range/MotionLimited Range/MotionNo Range/Motion
Forearm – turning to palm down			Typical Range/MotionLimited Range/MotionNo Range/Motion
Wrist – moving left and right			Typical Range/MotionLimited Range/MotionNo Range/Motion
Wrist – moving up and down			Typical Range/MotionLimited Range/MotionNo Range/Motion
Thumb – touching pinky			Typical Range/MotionLimited Range/MotionNo Range/Motion
Thumb – bending finger joints			Typical Range/MotionLimited Range/MotionNo Range/Motion
Pointer finger – bending finger joints			Typical Range/MotionLimited Range/MotionNo Range/Motion
Middle finger – bending finger joints			Typical Range/MotionLimited Range/MotionNo Range/Motion
Ring finger – bending finger joints			Typical Range/MotionLimited Range/MotionNo Range/Motion
Pinky finger – bending finger joints			Typical Range/MotionLimited Range/MotionNo Range/Motion

Background Information and Occupational Intake – Adult

Background Information

Referring Information

Medical History

Self-Care Skills

Range of Motion (ROM) / Pain Levels

Sensory Processing Checklist

Antelope Valley

Los Angeles

San Gabriel Valley

Bakersfield