TheraKids Plus, Inc. Occupational Therapy Questionnaire Behavioral History Form - English Patient Name(Required) First Last Contact Phone Number Date of Birth(Required) MM slash DD slash YYYY EARLY HISTORYWas your child a quiet baby? Yes No Describe: Was your child cranky as a baby? Yes No Describe: Would you characterize your baby as “content or happy”? Yes No Describe: SOCIAL AND PLAY SKILLSPrefers to play alone? Yes No Sometimes Describe: Plays alongside other children or does not interact with others? Yes No Describe: Tantrums when items / toys are removed or activities are changed? Yes No Describe: Frequently lines objects or toys in a row? Yes No Sometimes Becomes upset if items or toys are moved or play is interrupted? Yes No Sometimes Holds (clutches) items for extended periods of time? Yes No Sometimes Has unusual interest or uses toys in odd ways (flipping strips of paper, electrical cords etc.)? Yes No Sometimes Describe: Spins objects? Yes No Sometimes Other concerns: ACTIVITY LEVEL / CONDUCT Please check all that apply.Behavior Difficult to manage behaviors Consistently Occurs Sometimes Occurs Almost Never Occurs Displays poor eye contact Consistently Occurs Sometimes Occurs Almost Never Occurs Has repetitive behaviors Consistently Occurs Sometimes Occurs Almost Never Occurs Has temper tantrums Consistently Occurs Sometimes Occurs Almost Never Occurs Overly active Consistently Occurs Sometimes Occurs Almost Never Occurs Sluggish / delayed responses Consistently Occurs Sometimes Occurs Almost Never Occurs Poor attention span Consistently Occurs Sometimes Occurs Almost Never Occurs Destroys property Consistently Occurs Sometimes Occurs Almost Never Occurs Aggressive towards peers and or adults Consistently Occurs Sometimes Occurs Almost Never Occurs Abusive to self Consistently Occurs Sometimes Occurs Almost Never Occurs Infatuated with death or dying Consistently Occurs Sometimes Occurs Almost Never Occurs Has trouble transitioning between activities/routines Consistently Occurs Sometimes Occurs Almost Never Occurs Responds to discipline / structure Consistently Occurs Sometimes Occurs Almost Never Occurs Has unusual fears Consistently Occurs Sometimes Occurs Almost Never Occurs Gets in trouble at school Consistently Occurs Sometimes Occurs Almost Never Occurs Runs away from area / home Consistently Occurs Sometimes Occurs Almost Never Occurs Understands dangerous situations Consistently Occurs Sometimes Occurs Almost Never Occurs
