History Intake Form

Child's Name(Required)

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Form Completed By(Required)

First Last

Relationship to child(Required)

Pediatrician's Name, Phone Number, and Fax Number(Required)

Who referred you to physical therapy and why?(Required)

What are your concerns?(Required)

Child's birthdate(Required)

Gender(Required)

Birth History

Was your child adopted?(Required)

If so, at what age?

Length of pregnancy(Required)

in weeks

Delivery type(Required)

Birth Weight(Required)

in pounds and ounces

Name of hospital(Required)

Were there any complications during pregnancy?(Required)

If yes, please describe.

Please list any medications used during pregnancy

Were there any complications during labor?(Required)

If yes, please describe.

Was a NICU stay required?(Required)

If yes, how long and why?

What interventions were required?

Social and Medical History

Does the child live with any siblings?(Required)

If so please list ages.

What are the primary languages spoken at home?(Required)

Does your child have any known allergies?(Required)

Does your child currently take any medications?(Required)

If yes, please list

Has your child had any surgeries, major illnesses, or hospitalizations?(Required)

If yes, please list

Has your child had ear infections?(Required)

If yes, how many?

Were they treated by antibiotics?(Required)

Has your child received a formal vision test?(Required)

If yes, when

Has your child received a formal hearing test?(Required)

If yes, when

Other significant medical history?

Please indicate any specialists your child currently sees and if any follow-ups scheduled?

Developmental history

Age when child sat independently?

Age when child crawled on hands and knees?

Age when child walked?

Age when child spoke first word?

Did your child tolerate tummy time as a baby?

Has your child been evaluated or received therapy previously(Required)

If yes, what type of therapy and what was the reason and duration?

Is there anything else you would like us to know?

Digital Signature(Required)

By submitting this document and entering your name on is line, you agree that this information is truthful.

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