Pediatric Physical Therapy Medical History Form
Child’s Information:
- Full Name:
- Preferred Name:
- Date of Birth:
- Age:
- Gender: ☐ Male ☐ Female ☐ Other
- Address: _______________________________________________
- City: ________________________ State: _______ Zip: ________
- Parent/Guardian Name:
- Contact Number:
- Email:
- Second Parent/Guardian Name:
- Contact Number
- Email:
- Emergency Contact Name:
- Emergency Contact Number:
- Physician Name:
- Physician Practice:
Medical History:
- Diagnoses/Conditions:
- Date of Diagnosis: _______________ (MM/DD/YYYY)
- Previous Surgeries or Hospitalizations:
- Date: Procedure:
- Date: Procedure:
- Date: Procedure:
- Current Medications:
- Name: ____________________ Dosage:
- Name: ____________________ Dosage:
Developmental History:
- Pregnancy and Birth:
- Full Term? ☐ Yes ☐ No
- Complications during pregnancy or delivery? ☐ Yes ☐ No
- If yes, please describe: _______________________________________________
- Milestones:
- Crawled: _______________ (Age)
- Walked: _______________ (Age)
- Any delays in reaching developmental milestones? ☐ Yes ☐ No
- If yes, please specify: _____________________________________________
Physical Activity and Lifestyle:
- Current Activities/Sports: ___________________________________________
- Previous Physical Therapy:
- Provider: ____________________ Duration: _______________
- Goals of therapy: _______________________________________________
- Was it effective? ☐ Yes ☐ No
- Current Limitations in Activity: _____________________________________
- Interests in Physical Activity: ______________________________________
Family Medical History:
- Does anyone in the family have a history of:
- Neurological Disorders? ☐ Yes ☐ No
- Musculoskeletal Disorders? ☐ Yes ☐ No
- Other relevant conditions? _____________________________________
Additional Information:
- Are there any allergies? ☐ Yes ☐ No
- If yes, please list: __________________________________________
- Any additional comments or concerns: _______________________________