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
2 digit month, 2 digit day, 4 digit yearDate
Child's Name:
Age:
Birth Date:

MonthDayYear
Sex:
My Child is:
Please explain your relationship to the child
Parent/Guardian 1 Name:
Relationship to child
Parent/Guardian 1 Cell Phone Number

Area CodePhone Number
Please send me text reminders:
I would like my reminder:
Parent/Guardian 1 Email address:
Parent/Guardian 1 Date of Birth:
Parent/Guardian 2 Name:
Relationship to Child
Parent/Guardian 2 Cell Phone Number

Area CodePhone Number
Parent/Guardian 2 Email Address:
Parent/Guardian 2 Date of Birth:
Who has legal custody of the child?

Other
Who is legally authorized to make health care/therapy decisions for the child?

Other
Is there a court order, custody agreement, guardianship document, Delegation of Parental Authority (DOPA), or other legal document that affects who may make health care decisions or receive information about this child?
Please upload any applicable documents:

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Is anyone other than a parent or legal guardian authorized to make health care/therapy decisions for this child?
If yes, please provide their name
Relationship to the child
Type of Legal Authority (please provide a copy of the current documentation via email or fax)

Other
Are there any restrictions on contacting or providing information to any parent, guardian, or other individual associated with this child?
Please explain
Please provide documentation (if different from above upload)

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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?
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

Rows	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:
Are immunizations current
Explanation of medical history items:
Has your child ever had
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

Rows	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
Should be Empty:

Physical Therapy Child Intake Form (ages 0-2)

Medical History

Developmental Milestones

Strengths, Areas of Improvement, & Goals

Insurance Information and Signatures