Patient Intake Form

Date*

Referred by:

Reason for referral:*

Physical Therapy Evaluation
Orthotic Evaluation
Wheelchair/Seating Evaluation
Equipment Evaluation
Speech Evaluation
Feeding and Swallowing Evaluation
Occupational Therapy Evaluation

What type of equipment are you needing?

Patient Information

Child's Name*

First Last

Date of Birth (DOB)*

Address*

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

Age*

Gender*

Height

Weight

Diagnosis

School Name

City

School Physical Therapist or Teacher:

Who lives at home?

Siblings:

Contact Information

Mother's Name*

First Last

Home Phone

Work Phone

Cell Phone*

Email*

Address same as above?

Yes
No

Address

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

Father's Name

First Last

Home Phone

Work Phone

Cell Phone

Email

Address same as above?

Yes
No

Address

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

Emergency Contact

First Last

Emergency Contact Phone

Emergency Contact Relationship

Pediatrician

Pediatrician Phone

Insurance

Primary Insurance:*

Responsible Party

Relationship to Patient

Primary: Phone Number

Primary: Policy number*

Primary: Group Number

Secondary Insurance:

Responsible Party

Relationship to Patient

Secondary: Phone Number

Secondary: Policy number

Secondary: Group Number

General Health History

Was your child:

Full Term
Premature

Gestational Age

Birth Weight

Complications during birth/pregnancy:

At what age did your child:

Current Medications

Allergies

Has your child seen any of the following specialists?

If other, list here:

Name of specialist/date last seen:

Has your child ever been hospitalized/surgeries?

Has your child ever been treated for?

If other, list here:

Explain:

Areas of Concern

Consent*

I agree to the privacy policy. Please Note: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our office.

New Patient Form

Patient Information

Contact Information

Insurance

General Health History