Forms - Moving And Grooving Pt

Moving And Grooving Pt

Home
About Us
- WHAT WE DO
- WHY CHOOSE US
Services
- Pediatric Physical Therapy
Who Needs Physical Therapy?
Testimonials
Forms
Contact Us

Home
About Us
- WHAT WE DO
- WHY CHOOSE US
Services
- Pediatric Physical Therapy
Who Needs Physical Therapy?
Testimonials
Forms
Contact Us

Se habla español

PAPERWORK & PAYMENT

OR

Pay VIA

NOTE: For classwallet click on link and and select Moving and Grooving PT

Questions about whether your child qualifies for ESA? https://www.azed.gov/esa

Does your heart say yes but your wallet says no? Ask us about scholarships and what you can do to earn services for a discounted rate.
Contact Us

Intake Paperwork for Moving and Grooving Pediatric Physical Therapy

With whom does the child live:

Bio Parents Foster Parents Extended Family

Emergency contact (name, relationship, phone):

Preferred means of Contact: Email/ Text/ Phone

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

Home Childcare Extended Family

Which specialties follow your child?

Specialist Reason Frequency

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

Has your child had a vision/hearing test?

Yes No

Wear glasses?

Yes No

Has your child had any of the following:

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

Yes No

Were there infections/illnesses/difficulties during pregnancy?

Yes No

Receive any medication during pregnancy?

Yes No

Have any complications/difficulties during delivery/labor?

Yes No

Vaginal C-Section

Require:

Forceps Vacuum

Breech (feet first):

Yes No

Any birth injuries?

Yes No

Jaundice:

Yes No

Breast or Bottle Fed (circle one)

Breast Bottle

Was the child primarily fed on their left or right side? (circle one)

Left Rigth Both

Are there feeding concerns?

Are there sleeping concerns?

Are there concerns with colic or fussiness?

Does your child avoid any positions?

Where is tummy time performed?

Ground Bed Parent’s Chest Boppy

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

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

Roll tummy to back Roll back to tummy Sat independently Army crawl Hands and knees crawl Other modes of floor mobility Pull to stand Cruise Stand independently Walk independently

HOME
ABOUT US
WHO NEEDS PT?
BLOGS
FORMS
FAQ
CONTACT US

Meeting Milestones One Day at a Time

952-797-3094
nikki@movingandgroovingpt.com

Facebook-f Instagram Whatsapp

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.