Pediatric (18 and Younger) Patient Intake Form

PATIENT INTAKE FORM PEDIATRIC(18 and younger)
Date*

MonthDayYear
Date
NAME:*

First NameLast Name
DATE OF BIRTH:*

MonthDayYear
Date
AGE:*
PREFERRED PRONOUNS:*
DOMINANT HAND:*
Height:*
Weight:*
BIRTH SEX:*
AGE OF FIRST MENSES:
ARE THEY REGULAR:

YESNO
WHO'S IS THE PATIENT'S LEGAL GUARDIAN:*
WHO IS WITH THE PATIENT TODAY*
NAME OF SCHOOL AND IN WHAT GRADE*
MEDICAL HISTORY
CURRENT MEDICATIONS: NAME, DOSAGE AND INSTRUCTIONS:
PAST/CURRENT MEDICAL PROBLEMS*
PAST SURGERIES*
PAST HOSPITALIZATIONS*
PAST FRACTURES/BONE STRESS INJURIES:*
PAST MUSCULOSKELETAL INJURIES:*
IMMUNIZATIONS UP TO DATE: *
ALLERGIES:*

NOYES
PLEASE LIST YOUR ALLERGIES:
DO YOU TAKE VITAMINS OR SUPPLEMENTS?*

NOYES
PLEASE LIST THE VITAMINS OR SUPPLEMENTS YOU TAKE:
DO YOU CURRENTLY (PAST 6 MONTHS) USE ANY OF THE FOLLOWING: (CHECK THOSE THAT APPLY)

MARIJUANAALCOHOLTOBACCOOTHER:
FAMILY HISTORY DOES ANYONE IN THE PATIENT'S FAMILY HAVE PROBLEMS WITH THEIR:

OTHER FAMILY PROBLEMS NOT LISTED ABOVE:
REVIEW OF SYSTEMS DOES THE PATIENT HAVE PROBLEMS WITH ANY OF THE FOLLOWING: (CHECK ALL THOSE THAT APPLY)

EYES/VISIONBLEEDINGSKIN/RASHESEARS/NOSE/THROATPSYCHIATRIC ILLNESSCARDIAC/VASCULARLUNGS/BREATHINGJOINT PAINNEUROLOGICAL SYMPTOMSWEAKNESS/FATIGUEIMMUNE DYSFUNCTIONWEIGHT LOSSCHEST PAINURINARY TRACTEXPLAIN:
SPORTS DEMOGRAPHICS:
DO YOU PLAY ORGANIZED SPORTS?*

NOYES
HOW MANY TOTAL HOURS PER WEEK DO YOU EXERCISE?*
WHAT IS YOUR PRIMARY SPORT?*
WHAT POSITION DO YOU PLAY?*
HOW MANY HOURS PER WEEK DO YOU PLAY THIS SPORT?*
WEEKS PER YEAR?*
WHAT LEVEL COMPETITION (CHECK ALL THAT APPLY)

RECREATIONALSCHOOL TEAMCLUB/TRAVELOTHER
WHAT OTHER SPORTS DO YOU PLAY?*
HOW MANY HOURS PER WEEK DO YOU PLAY THESE OTHER SPORTS?*
WEEKS PER YEAR?*
INJURY DEMOGRAPHICS
DATE OF INJURY

MonthDayYear
Date
INJURED BODY PART (INCLUDE LEFT, RIGHT, BOTH)*
WHAT SPORT WERE YOU PLAYING OR ACTIVITY WERE DOING WHEN INJURED?*
DESCRIBE THE INJURY AND HOW IT OCCURRED*
WERE YOU ABLE TO CONTINUE PLAYING/COMPETING AFTER THE INJURY?*

YESNO
WERE YOU TAKEN TO ER/URGENT CARE/PRIMARY CARE?*

NOYES
WHEN AND WHERE DID YOU GO TO RECEIVE CARE:*
WHAT TESTS WERE DONE THERE?*

X-RAYSCTMRIBLOOD TESTOther
WHAT WAS THE PHYSICIAN’S FINAL DIAGNOSIS?*
WHAT WAS DONE TO TREAT YOUR INJURY?

CASTBRACEPHYSICAL THERAPYSURGERYOther
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PATIENT INTAKE FORM PEDIATRIC(18 and younger)