Pediatric Growth Rehabilitation Assessment Form
Please complete this assessment to help evaluate the child's growth and rehabilitation needs for clinical intake.
Child's Initials
*
Child's Age (years)
*
Sex
*
Male
Female
Other/Prefer not to say
Primary Reason for Assessment
*
Growth concern
Developmental delay
Physical disability
Other
Current Mobility Status
*
Independent
Needs assistance
Wheelchair user
Unable to ambulate
Growth Pattern Compared to Peers
*
1
2
3
4
5
Functional Skills Assessment
*
Rows
Not at all
Some difficulty
Age-appropriate
Self-feeding
1
2
3
Dressing
4
5
6
Communication
7
8
9
Mobility
10
11
12
Pain or Discomfort Present?
*
Yes
No
Overall Rehabilitation Needs
*
1
2
3
4
5
Additional Comments or Observations
Submit Assessment
Should be Empty: