PHYSICAL THERAPY INTAKE FORM (INFANT AND TODDLER)
Name
*
Child's First Name
Child's 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 who diagnosed, 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?
Hip popping/clicking
Preferring to look one direction
Head tilt
Flattening of the head
Has your child received a hip screen for hip dysplasia?
Yes
No
Does your child have a history of having a hip x-ray or ultrasound?
Yes
No
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
DEVELOPMENTAL MILESTONES:
At what age did your child first perform the following?
Lift head while on tummy
Army crawl on belly
Crawl on hands and knees
Pull up to knees at surface
Stood alone
Cruise on furniture
Climb onto surface (couch, chair)
Walked on stairs
Babbled
Spoke Single Words
Have you observed your child to prefer to use one side of their body more than the other?
Yes
No
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
Time Spent during the day: On belly
Time Spent during the day: On back
Time Spent during the day: Car seat
Time Spent during the day: Positioning devices (swings, bouncy seat, bumbo, jumper)
Time Spent during the day: Floor
Does your child use any of the following at home or at school?
Infant Swing
Exersaucer
Infant "walker" or jumper
Helmet
Other
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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