Physical Therapy Intake Form
Personal Information
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Child's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Male
Female
Other
Parent Name
First Name
Last Name
Occupation
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Parent Name
First Name
Last Name
Occupation
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other Contact
(Optional: caregiver, family member, babysitter, nanny, etc)
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Relation to Child
Referred By
First Name
Last Name
Pediatrician
First Name
Last Name
Pediatrician Phone Number
-
Area Code
Phone Number
Reason for Today's Evaluation
Please list the primary concerns for your child at this time:
When did you notice these concerns?
Does your child have any medical diagnoses we should be aware of?
Has your child received previous evaluation or treatment therapies?
Yes
No
If yes, what kind and where?
Does your child attend daycare, school or any other program?
Yes
No
If yes, where and what is his or her schedule?
Does your child have an IEP or 504 plan?
History
Birth History/ Complications
Rows
Yes
No
Premature Birth
Jaundice
Breathing Difficulty
Tube Fed
Emergency Cesarean
Low APGAR
Forceps/Vacuum
Congenital Defects
Transfusion
Other Complications
Where was your child born?
Hospital
Home
Birthing Center
Term:
Weeks
Birth weight and length:
Was your child in the NICU? If so, how long?
If yes, what was the reason?
Other comments regarding pregnancy/birth history:
Medical History
Fatigue
Failure to thrive
Frequent colds/ respiratory condition
Head injuries/ concussions
Heart condition
Seizures
Joint or bone condition
Allergies or asthma
Visual disorders
Neurological disorder
Birth defects/genetic disorder
Anemia/ blood disorder
Feeding condition
Trauma
Frequent ear infections
Autism Spectrum Disorder
Constipation
Muscle disorder
Urinary infections/ condition
None
Other
Does your child have any allergies?
Does your child take any daily medication(s)?
Has your child has any imaging or special tests?
X-ray
CT Scan
MRI
EEG
If yes, please describe the results and the date the imaging/special test was performed.
Please identify all infant behaviors that apply to your child as an infant:
Rows
Yes
No
Floppy when held
Alert
Cried a lot/ fussy
Drooled excessively
Liked being held
Irregular sleep patterns
Quiet or passive
Has your child received all recommended vaccines?
Yes
No
*If no, please explain:
Developmental History
Rows
How old was your child when he or she first:
Rolled Over
Sat Independently
Creeped/Crawled on Hands and Knees
Pulled to Stand
Walked Independently
Produced a Single Word
Produced a Sentence
Drank from an Open Cup
Chewed Solid Food
Submit Form
Should be Empty: