Physical Therapy Intake Form

Your Name*
Phone*
Child's Name*
Birthday*
MM slash DD slash YYYY
Current Medical Diagnosis:*
School:
Grade:
Teacher:
What physical or developmental behavior is your biggest concern about your child?*
Does your child current or has he/she previously received any therapy services? If current, please list details:*
Medical History
Significant birth history?*
Siblings? Please include names and ages (list any previous therapies received):*
Significant surgical history?*
Significant recurrent health problems (including asthma, ear infections, etc.)?*
Current medications?*
Primary language?*
Community activities (including sports teams, classes, park district programs, play groups, church groups, etc)?*
Developmental History/Motor Milestones:
When did your baby first--?
Rolled:
Crawled:
Sat independently:
Cruising around furniture:
Walk:
How can we help? What would you like from today’s evaluation?

Medical History