PHYSICAL THERAPY INTAKE FORM (SCHOOL AGED 3+)
Name
*
Childs First Name
Childs Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
CHILD’S EVALUATION AND TREATMENT HISTORY:
Please describe why you are having your child evaluated:
CHILD’S MEDICAL HISTORY:
Has your child received a new diagnosis since completion of the initial PAT medical history paperwork?
Yes
No
If yes, please provide details (diagnosis, physician, date of diagnosis)
Please list any changes in medication since completing your child’s initial PAT medical history paperwork including medication, frequency, physician who prescribed, and start date:
Has your child had any accidents/Injuries?: If yes, please provide age and type of injury (head, abdomen, fracture etc)
What is your child’s current height?
Weight?
Does your child have a history of the following?
Torticollis
Plagiocephaly
Brachycephaly
Hip Dysplasia
Does your child have a history of orthotic wear?
Yes
No
If yes, what type?
Shoe Insert
SMO
AFO
Night Splints
TLSO
Cranial Orthotic
Other
SCHOOL:
(Please bring a copy of your IEP/IFSP if not already on file)
Is your child involved in organized activities or sports at school?
Yes
No
If yes, please describe.
DEVELOPMENTAL MILESTONES:
At what age did your child first perform the following?
Crawled on hands and knees
Stood alone
Toilet Trained
Climbed onto surface (couch, chair)
Walked up stairs without assist (with handrail)
Walked down stairs without assist (with handrail)
Run
Skipped
Rode tricycles
Rode bike with training wheels
Bike without training wheels
Has your child crawled in a pattern other than hands and knees? (Ex: “tripod” or scooting)
Yes
No
Do you have concerns for the following?
Strength
Endurance/Fatigue
Posture
Balance
Walking Pattern
Running Pattern
Playground Play
Coordination
Skin Conditions
Breathing Rate/Pattern
Cold Extremities
Digestion
Decreased Pain Tolerance
Increased Pain Tolerance
When your child is standing or walking do you have concerns for the following?
Toe Walking
In-toeing
Out-Toeing
"knock kneed"
"Bow legged"
Frequent tripping/falling
GOALS:
Please list goals that relate to anything your child cannot do that interferes with his/her daily function that you would like to help address through Physical Therapy. #1
Please list goals that relate to anything your child cannot do that interferes with his/her daily function that you would like to help address through Physical Therapy. #2
Please provide any other information that you would like your evaluating therapist to know about your child:
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