Physical Therapy Intake Form | Lori Kilpatrick Pedi

Physical Therapy Patient Intake Form

PHYSICAL THERAPY NEW PATIENT
INTAKE FORM

Please complete the new patient Physical Therapy history information intake form below.

CHILD INFORMATION

Child Full Name

Child Date of Birth

Parent/Legal Guardian Name

Phone

PHYSICAL MEDICAL HISTORY

Please list any previous/current therapies?

Is your child currently in any pain? If yes, please describe.

On a scale 0 - 10, 0 being very little pain, 10 very bad pain) how bad does your child say they are currently in pain?

What age did your child roll over?

What age did your child sit up alone?

What age did your child crawl?

What age did your child pull up to stand?

What age did your child walk?

Describe your child's likes and dislikes?

What word best describes your child's behavior?

List any activities you feel your child should be doing but is not currently doing?

SIGNATURE

By checking this box and signing below, I agree to the terms listed within this form. I confirm that I am the authorized parent/legal guardian for the child as detailed within this form.

Your Signature

Thanks for submitting our patient intake form. You may click the link below to return to the home page.

Please click the button to complete the intake form for the services you are seeking for your child.