Intake Paperwork | Moving & Grooving Pediatric Physical Therapy

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Pediatric Physical Therapy Services
Does My Child Need PT?
Resources
- Forms
- Blog
- FAQ
- Testimonials
About
Contact
Book Online

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Intake Paperwork for Moving and Grooving Pediatric Physical Therapy

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Child's Name:

Birth Date:

MM slash DD slash YYYY

Actual Age:

Parents Name:

Marital Status:

With whom does the child live:

Bio Parents

Foster Parents

Extended Family

Name[s] and Age of sibling:

Name[s] and Age of sibling:

Name[s] and Age of sibling:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency contact:

First Middle Last

Preferred means of Contact:

Email

Text

Phone

Where and with whom is your child for the majority of the day:

Home

Childcare

Extended Family

Name of Daycare/Preschool (if applicable):

Referred by (name, profession, phone number):

Pediatrician’s name:

Reason for referral:

Medical diagnoses:

Medical diagnoses:

Medical diagnoses:

Medical diagnoses:

Medical diagnoses:

Which specialties follow your child?(Last Date of Visit, and Finding/ Imaging)

Specialist/Reason/Frequency

Specialist/Reason/Frequency

Which specialties follow your child?(Last Date of Visit, and Finding/ Imaging)

Specialist/Reason/Frequency

Specialist/Reason/Frequency

Which specialties follow your child?(Last Date of Visit, and Finding/ Imaging)

Specialist/Reason/Frequency

Specialist/Reason/Frequency

Which specialties follow your child?(Last Date of Visit, and Finding/ Imaging)

Specialist/Reason/Frequency

Specialist/Reason/Frequency

Which specialties follow your child?(Last Date of Visit, and Finding/ Imaging)

Specialist/Reason/Frequency

Specialist/Reason/Frequency

If Applicable:

Has your child received any previous therapy services:

Has your child received any previous therapy services:

Has your child received any previous therapy services:

Please list which therapy services, the dates of therapy, and the company and professional’s name:

What was the reason therapy services have stopped (circle one)?

Scheduling difficulties

Cost

Interaction with Staff

Met Goals

Self Discharged

Has your child been referred to or evaluated by AZEIP?

Yes

No

Did they Qualify:

Yes

No

Child’s DOB:

Gestation:

Birth weight (lb, oz):

Has your child had a vision/hearing test?

Yes

No

Result

Wear glasses?

Yes

No

Do you have concerns about their hearing or vision?

Has your child had any of the following: If yes, describe and give approximate dates:

Childhood diseases or major illnesses

Childhood diseases or major illnesses

Congenital abnormalities

Congenital abnormalities

Congenital abnormalities

Surgery

Surgery

Surgery

Serious injury

Serious injury

Serious injury

Hospitalizations

Hospitalizations

Hospitalizations

Ear infections

Ear infections

Ear infections

Tubes in ears

Tubes in ears

Tubes in ears

Allergies

Allergies

Allergies

Seizures

Seizures

Seizures

Medication use (prior and current)

Medication use (prior and current)

Medication use (prior and current)

Are there any medical precautions we should be aware of when working with your child:

Yes

No

Please explain:

Maternal health during pregnancy:

Were there infections/illnesses/difficulties during pregnancy?

Yes

No

Describe:

Receive any medication during pregnancy?

Yes

No

Describe:

Have any complications/difficulties during delivery/labor?

Yes

No

Describe:

Vaginal

C-Section

If C-Section: Scheduled/Emergency

Require:

(circle one)

Forceps

vacuum

Breech

(feet first):

Yes

No

Any birth injuries?

Yes

No

Describe:

Jaundice:

Yes

No

Length of Hospital Stay:

Length of NICU Stay:

Infancy and Early Childhood

Breast or Bottle Fed

(circle one)

Breast

Bottle

Was the child primarily fed on their left or right side?

(circle one)

Left

Right

Are there feeding concerns?

Yes

No

If yes, Describe

Are there sleeping concerns?

Yes

No

If yes, Describe

Are there concerns with colic or fussiness?

Yes

No

If yes, Describe

What position is your child in for the majority of the day?

Does your child avoid any positions?

Yes

No

If yes, Describe

How many minutes at a time do/did they tolerate tummy time?

Where is tummy time performed?

Ground

Bed

Parent’s Chest

Boppy

Does your child utilize or look towards one side of their body?

Yes

No

If yes, Describe

Developmental Milestones: Please note the approximate age in months your child did the following:

Roll tummy to back

Developmental Milestones: Please note the approximate age in months your child did the following:

Roll back to tummy

Roll back to tummy

Roll back to tummy

Roll back to tummy

Sat independently

Sat independently

Army crawl

Army crawl

Army crawl

Hands and knees crawl

Hands and knees crawl

Hands and knees crawl

Other modes of floor mobility

Other modes of floor mobility

Other modes of floor mobility

Pull to stand

Pull to stand

Pull to stand

Cruise

Cruise

Cruise

Stand independently

Stand independently

Stand independently

Walk independently

Walk independently

Walk independently

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Meeting Milestones One Day at a Time

952-797-3054
nikki@movingandgroovingpt.com

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HOURS OF AVAILABILITY

Monday to Thursday: 08:00 AM – 05:00 PM
Friday: 08:00 AM – 02:00 PM

*Appointments can be scheduled as needed,
including before or after work or on Saturdays.

© 2023 Moving and Grooving Pediatric Physical Therapy

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