INTAKE FORM | Dynamic Kids Physical Therapy

Child's Name

Date of Birth

Age

Parent/Guardian(s) #1

Address

Phone Number

Parent/Guardian(s) #2

Home Address (if different)

Phone Number

Emergency Contact

Phone Number

School/Grade

Child's Diagnosis

Other Doctors/Specialists Your Child Sees

List Prior Surgeries

Hospitalizations

Current Medications

Allergies

Insurance Company

Does Your Child Have the Following

Communication device

Breathing Difficulties

Seizures

Intrathecal baclofen pump

Botox injections

Hearing impairment

Vision impairment

Behavior concerns

Other medical precautions

Please explain any selections above

Check assistive technology your child uses

How Does Your Child Communicate

Is Your Child Continent

Yes

No

Can Your Child Follow 1 Step Directions?

Yes

No

Does Your Child Have Sensitivity to

What are your child's favorite toys or activities?

Motor Skills | Check all that apply

Please provide details.

Therapy Background

Has your child experienced

Kinesiotape

Theratogs

Electrical stimulation

Body weight support treadmill training

Prior intensive PT session

Describe a positive experience your child has had with PT.

Has your child had any negative or difficult situations in therapy that we should know about?

List your top 3 goals for your child

What do you hope your child achieves with a PT intensive session?

List any questions or concerns that you have for your child regarding intensive physical therapy.

Patient Intake Form

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