Infant PT Intake Form

Physical Therapy Child Intake Form (ages 0-2)
Please Note: Every question included in this intake is used to adequately prepare for your child's evaluation (i.e., select appropriate assessments, prepare the evaluation space, etc). Each question must be answered before your evaluation can begin.
Today's date:*

MonthDayYear
Date
Child's Name:*
Age:*
Birth Date:*

MonthDayYear
Sex:*
My Child is:*
Caregiver 1 Name:*
Caregiver 1 Phone Number*

Area CodePhone Number
Please send me text reminders:*
Caregiver 1 Email*
example@example.com
Caregiver 2 Name:
Caregiver 2 Phone Number

Area CodePhone Number
Caregiver 2 Email
example@example.com
If caregivers are not present in the session, therapists often check-in before and after the session to hear about any changes at home/school and what we did in therapy. We will ask you to join us in a room for any personal or in-depth updates. For routine check-ins, are you comfortable discussing this in the lobby? If not, we will ask you to join us in a private room. You may change your mind at any time, but please tell your therapist or the front desk.*
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Who currently lives with this child?*
Primary language spoken in the home:*
Physician/Primary Care Provider*
Primary Care Provider Clinic Name*
How did you hear about us:*
Medical Diagnosis:
Allergies:
Current Medications:
School/Program of attendance:
Does your child receive Special Education Services?*
If, yes, what?

AcademicBehavioralOccupationalSpeechPhysicalSocial SkillsD/APE
Describe your current concerns:*
If Torticollis, specify preferential head position
Equipment (braces, helmet, etc):
Please list past evaluations and therapy:
Is your child currently receiving therapy at this time?*
If yes, what type of therapy and where?
Family members that have any significant diagnoses (ADHD, learning disability, etc):

Prenatal/Birth History*

	Yes	No	Unknown
Illness/Accidents during pregnancy
Pregnancy/delivery concerns
Full term
Alcohol/tobacco/medication use during pregnancy
Vaginal Delivery
C-section delivery
Assisted delivery (forcep, vacuum)
Feeding difficulties

Additional details for prenatal/birth history (weeks premature, concerns, etc):
Medical History
History of:*

SeizuresHistory of high feversPneumoniaSinusitisWhooping coughCroupTonsillitisChronic coldsEnlarged glandsHeart troublesAsthmaChronic ear infectionsTramatic Brain InjuryOtherNone of the above
Are immunizations current*
Explanation of medical history items:
Has your child ever had*

Serious/recurrent illnessesOperationsAccidentsVision problemsHearing difficultiesPE tubesDental problemsOtherNone of the above
Description of above medical concerns:
Developmental Milestones
Did your child:
Rolled by 4-5 months?*
if no, at what age?
Sit up independently by 8 months?*
if no, at what age?
Rocked on hands & knees by 8 months?*
if no, at what age?
Crawl by 11 months?*
if no, at what age?
Pulled to stand on furniture 10-11 months?*
if no, at what age?
Walk by 15 months?*
if no, at what age?
Babbled by 6 months?*
if no, at what age?
Said first words by 16 months?*
if no, at what age?

Did your child have difficulty*

	Yes	No	Unknown
Sucking
Swallowing
Chewing
Changing to solids

Strengths, Areas of Improvement, & Goals
3 strengths of my child are:*
3 areas of improvement my child has are:*
3 goals I have for my child are:*
Insurance Information and Signatures
Insurance Carrier*
Policy Holder*
Employer*
Group Number*
Policy Number*
Does your child have secondary insurance?*
Secondary Insurance Carrier*
Secondary Policy Number*
I have custody for the above minor and have been granted the right to legally make all health/therapy decisions regarding him/her. Please list others that share custody and are priveledged to health information:
Others than yourself who have custody of the above named minor:
Signature of parent/guardian*

Clear
Should be Empty:

Physical Therapy Child Intake Form (ages 0-2)

Medical History

Developmental Milestones

Strengths, Areas of Improvement, & Goals

Insurance Information and Signatures