What are your primary concerns with your child at this time? When did you first notice these concerns and how did they become apparent to you? Please describe the reasons for seeking physical therapy services at this time. Has your child received previous evaluations or interventions? If yes, what kind, where and when? Is your child currently receiving other interventions or therapies? Other: If yes, please list duration, location, and frequency. Does your child attend daycare, school or other programs? If yes, where and when? If no, what is his/her daily schedule? Who is home with him/her? Does your child participate in getting dressed? Does your child require assistance to: Please describe: Is your child toilet trained? Do toileting accidents occur? If yes, what time of day do the accidents typically occur? Does your child experience difficulty participating in any of the following activities? Please describe: Does your child have any medical diagnoses? If yes, please explain: Has your child had any of the following? Please check all that apply. Has your child had any major medical procedures / surgeries? If yes, please provide the date and results given. Has your child taken any medication for longer than 30 days / is your child taking any maintenance medications?
(Please list medication, time of day it is taken and what it is treating)
Has your child had any major medical illnesses
(e.g. chickenpox, hand, foot and mouth, croup, etc.)
Has your child received all of the vaccinations recommended by your pediatrician? If no, please explain. Has your child been hospitalized?
(Please list date and reason)
Has your child had a hearing test? If yes, please list date of test and results. Has your child had an eye exam? If yes, please list date and test results. Does your child wear glasses? Does your child experience difficulty with any of the following: If yes, what is his / her typical response? Does your child become frustrated easily? Does your child have friends? Does your child play with other children? What does your child enjoy doing? Does your child use toys the same way each time play occurs or is his / her play routine constantly changing and evolving? Please describe.