Clone of Sarasota Pain Treatment Medical Intake Form

Child's Daily Activities

In this section, the idea is to get a sense of what type and to what intensity and frequency of activities/movements, postures/positions, and exercise you get a regular basis.
Sarasota Pain Treatment Center
Medical Intake Form

By coming here, you have decided to take an active role in maintaining your most important asset, Your Health! Our staff includes some of the most respected and highly trained therapists in the world who are dedicated to help you attain a pain-free and healthy life. It is our pleasure to serve you.
NOTE TO PARENT / GUARDIAN: Please skip any sections that do not apply to your child.
Page 1: Personal Information
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
E-mail
Cell Phone Number

Area CodePhone Number
PARENT / GUARDIAN INFORMATION
Parent/Guardian 1 Full Name

First NameLast Name
Parent/Guardian 1 Relationship to Child
Parent/Guardian 1 Primary Phone

Area CodePhone Number
Parent/Guardian 2 Full Name

First NameLast Name
Parent/Guardian 2 Relationship to Child
Parent/Guardian 2 Phone

Area CodePhone Number
Is there a custody order that affects medical decision-making?
Answer only if YES above: Please describe or note that documentation is available
Answer only if YES above.
Child's Primary Care Physician
PCP / Pediatrician Name
Practice or Clinic Name
PCP Phone Number

Area CodePhone Number
Cell Phone Carrier
(i.e. ATT, Verizon, T-Mobile, Sprint)
Home Phone Number

Area CodePhone Number
Age
Years
Date of Birth

MonthDayYear
Gender
How did you hear about Sarasota Pain Treatment Center?

List any other health problems for which you are being treated:
Have you ever, to your knowledge, suffered a injury to your child's tailbone? (falls, sports injuries, playground accidents)
Answer only if you answered YES above: Please provide clarity about the incident. (falls, sports injuries, playground accidents)
Answer only if you answered YES above: Please provide clarity about the incident.
Have you ever, to your knowledge, endured a significant head trauma for your child from either a vehicle crash or sporting injury? (falls, sports injuries, playground accidents)
If you answered yes, please provide clarity about the injury… (falls, sports injuries, playground accidents)
Answer only if you answered YES above: Please provide clarity about the injury.
Sports, Hobbies & Play Activities
Child's Sleeping Position

NOTICE TO PARENT / GUARDIAN — TREATMENT COMFORT DISCLOSURE

Neurosomatic Therapy is a gentle, non-invasive approach to care, and our pediatric treatments are always performed with your child's comfort and safety as the highest priority. That said, as part of the therapeutic process, your child may experience mild discomfort or temporary sensitivity in certain areas during treatment.

This is a normal and expected part of the healing process. When soft tissue has been holding dysfunction — whether from postural imbalances, developmental patterns, or prior injury — releasing that tension can produce a brief sensation of pressure or tenderness. This is not harmful. It is the body responding to the correction of long-standing dysfunction, and it is precisely how Neurosomatic Therapy works.

We will always communicate with your child throughout the session, and we encourage your child to tell us if anything feels too intense. You are welcome and encouraged to remain present during treatment.

By signing below, you acknowledge that you have read and understand this notice and consent to treatment on behalf of your minor child.
I, the undersigned parent or legal guardian of the above-named minor child, hereby authorize Sarasota Pain Treatment Center to provide any and all information, copies, or records to any clinic, physician, lawyer, insurance company, or workman's compensation fund as deemed necessary. A copy of this authorization shall be considered as valid as the original.

I hereby authorize any physician to release any and all information and copies of all records to Sarasota Pain Treatment Center as deemed necessary for treatment of my minor child. A copy of this authorization shall be considered as valid as the original. I give permission that photographs and video footage may be taken of my minor child or their X-rays, CAT, or MRI scans during the course of treatment at Sarasota Pain Treatment Center. These photographs are strictly to be used for education for other healthcare practitioners and will not be displayed anywhere else without my written permission.
I AGREE TO THE ABOVE TERMS & CONDITIONS!
941-960-2096 / info@sarasotapaintreatment.com
1800 2nd St. Suite 760, Sarasota FL, 34236
Should be Empty:

Child's Daily Activities

Sarasota Pain Treatment Center

Medical Intake Form

NOTE TO PARENT / GUARDIAN: Please skip any sections that do not apply to your child.

Page 1: Personal Information

PARENT / GUARDIAN INFORMATION

Child's Primary Care Physician

About Your Condition

BIRTH & DEVELOPMENTAL HISTORY

SCHOOL & DAILY FUNCTION

IMMUNIZATION STATUS

GROWTH & DEVELOPMENT

Specialized Health History

Medical History

Lifestyle and Habits

PARENT / LEGAL GUARDIAN SIGNATURE

941-960-2096 / info@sarasotapaintreatment.com

1800 2nd St. Suite 760, Sarasota FL, 34236