NAPA Australia - Patient Intake Update

PATIENT INTAKE INFORMATION

Please answer as thoroughly as possible so we may have a better understanding of your child’s needs.

SUBMISSION DATE:

Date

Preferred Location:*

Program of Interest:*

PARENT/CARER DETAILS

Parent/Carer Name:*

First NameLast Name

Additional Parent/Carer:

First NameLast Name

Address (mark same if unchanged)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country:

Main E-mail Address:*

Secondary Contact E-mail Address:

example@example.com

Home Phone Number:

Mobile Phone Number:

PATIENT DETAILS

Child's First Name:*

Child's Last Name:*

Date of Birth:*

Date

Diagnosis:

Write 'undiagnosed' if applicable

Medicare Number:

Medicare Card Position Number:

Has their been any changes in your child's diagnosis?*

Current Medications:

Known Allergies & Reactions to Allergens:

Height:*

Current Weight:*

T-Shirt Size:*

Pant Size:*

Does your child wear shoes?:*

YesNo

Are they specific supportive shoes?:*

YesNo

Current Shoe Size (without AFOs)*

Does your child currently have AFOs or other orthotics?:*

YesNo

Type/Brand of Supportive Shoes:*

AFO or Other - Describe:

FAMILY:

Are there any other carers involved in your child's normal day or therapy regime?:

YesNo

If so, who?:

Does your child attend daycare, preschool, or school?:

YesNo

THERAPY HISTORY:

Physiotherapy:

Average Appointments

times per

Physiotherapy Clinic:

Most recent physiotherapy evaluation:

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Occupational Therapy:

Average Appointments

times per

Occupational Therapy Clinic:

Most recent OT evaluation:

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Speech Therapy:

Average Appointments

times per

Speech Therapy Clinic:

Most recent speech evaluation:

Browse Files

Any other therapy methods tried or currently used:

MEDICAL HISTORY:

Medical/surgical procedures since completing original intake paperwork?

Major Hospitalisations (since original intake completed).

Are your child's hips regularly monitored?:*

YesNo

If so, when was their last hip x-ray?

Date

Any history of hip subluxation/dislocation?:*

YesNo

Current hip subluxation/dislocation:

Left HipRight Hip

Degree (left):

Degree (right):

Most recent hip radiology reports (if applicable, please include the last 3 radiology reports)

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History of Heart Problems/Hypertension:

Is your child's diagnosis degenerative/progressive?*

If yes, please provide details below:

History of Seizures:

Are the seizures controlled?:

YesNo

Length of seizures:

When was the last seizure?

Date

What would typically trigger a seizure?:

Do you have a seizure management plan in place?:

YesNo

Any history/concerns of scolosis?:*

YesNo

If yes, what degree?:

GENERAL PHYSICAL:

What are your Gross Motor Goals for your child) (eg, rolling, crawling, walking)

What are your Fine Motor Goals for your child?: (eg. drawing, pointing, grasping)

COMMUNICATION:

Do you have any updates or concerns regarding your child's communication?*

Communication goals:

FEEDING AND SWALLOWING:

Do you have any updates regarding your child's feeding and/or swallowing?*

BEHAVIOUR:

Do you have any updates regarding your child's behaviour (likes, dislikes, etc.) or new behaviour concerns?

Behaviour goals:

Please Provide Contact Information of Specialists Who Treat Your Child

If unchanged, please indicate "unchanged" and we will refer back to your original intake paperwork.

General Practitioner

Name:

Group Practice Name:

City:

State:

Zip/Postal Code:

Country:

Office Phone Number:

Fax:

Orthopedic

Name:

Group Practice Name:

City:

State:

Zip/Postal Code:

Country:

Office Phone Number:

Fax:

Pediatrician

Name:

Group Practice Name:

City:

State:

Zip/Postal Code:

Country:

Office Phone Number:

Fax:

Neurologist

Name:

Group Practice Name:

City:

State:

Zip/Postal Code:

Country:

Office Phone Number:

Fax:

Please note, upon submission, you will receive an email including a link for you to sign our terms and conditions. This should take no longer than a few minutes to complete. We thank you for your time completing this form!

Additional Information:

Any other reports of documents you would like to share with us:

Browse Files

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