BAC Developmental Summary

DEVELOPMENTAL SUMMARY
Child's name:*

First NameLast Name
Child's date of birth:*
Child's pronouns*
Name of person completing this form*
Relationship to child*
Email address
example@example.com
What evaluations is your child scheduled to receive? (please be sure to check all that apply)*

Occupational TherapyPhysical TherapyPhysical Therapy for scoliosisSpeech/Language TherapyFeeding Therapy

REASON FOR SEEKING SERVICES
Occupational Therapy
What are your primary concerns related to OT services?*
Does your child's teacher have any concerns related to OT services?*
Physical Therapy
What are your primary concerns related to PT services?*
Were you recommended to pursue PT services by a physician, daycare, teacher, or other provider? If so, why?*
Speech and Language Therapy
What are your primary concerns regarding your child's communication development?*
Does your child's teacher have any concerns regarding your child's communication development?*
Do you have any concerns regarding your child's feeding and/or nutrition?*
Feeding Therapy
What are your primary concerns related to feeding?*

DEVELOPMENTAL MILESTONES
Did your child meet their developmental milestones on time? (i.e., rolling, sitting up, crawling, standing, walking, talking, etc.)*

Yes, my child met their milestones on par with their peers and/or siblings.No, my child met their milestones after their peers and/or siblings.Unsure
If no or unsure, please explain:*
Please indicate the approximate age at which your child met the motor milestones below:*
Current level of ambulation/transfers*
Please indicate the approximate age at which your child met the speech/language milestones below: (if applicable)

Other
Does your child have an established dominant hand?*

RightLeftUnsure
Does your child utilize any specialized equipment/bracing?*
Please list all languages your child speaks or is exposed to*
If your child is bilingual, when was your child exposed to English?*
If your child is bilingual, any concerns with your child's primary language?*
Please note that our evaluations will be completed in English. If you are seeking a bilingual language evaluation, please call for resources.

Rigo Concept Based on Schroth Method
What was your child's age when first diagnosed with scoliosis? *
What was the Cobb angle confirmed with X-ray when first diagnosed?*
Do you have a family history of scoliosis? If so, what is the relationship to your child? *
Has your child been seen by an orthopedic doctor? If so, what is the doctor's name? When was your child last seen by this doctor?*
When is the next time your child is scheduled to see an orthopedic doctor?*
Does your child wear a back brace? If so, how many hours of wear time was recommended by your child's orthopedic doctor? *
If your child wears a back brace, please list approximately when your child first started wearing their back brace.
Does your child wear ankle bracing, orthotics, or shoe lifts of any kind? If so, please describe what your child wears.*
When did your child last receive an x-ray of his/her spine? *
Does your child have back pain?*
For female patients - has your child started their period? If so, when did it start?
What are you hoping to get out of coming to physical therapy for scoliosis specific exercises using Rigo Concept based on the Schroth Method? *
Is there anything about your child's ability to learn that the physical therapist should know? (For example, does your child have trouble focusing? Does your child benefit from increased time to learn new information?) *

Is there anything else you would like to share regarding your child's development?
Should be Empty:

DEVELOPMENTAL SUMMARY