Aquatic Therapy Parent Assessment
Client Name *
Your answer
Parents Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Location of Interest *
Phone Number *
Your answer
E-mail *
Your answer
Primary Diagnosis *
Your answer
Secondary Diagnosis
Your answer
Subjective History (age of diagnosis, medical history, past therapies & interventions, etc.) *
Your answer
Current Medications *
Your answer
Medical Precautions *
Yes
No
Seizures
Diet
Allergies
Pain
Vision
Mobility
Bowel Incontinence
Bladder Incontinence
Respiratory Concerns
Auditory
Oral Motor
If checked "yes" to any of above, please explain.
Your answer
Mobility *
Behavioral Barriers to Participation *
Your answer
Communication Skills *
Your answer
Client/Caregiver Concerns and Goals *
Your answer
Current Aquatic Functioning *
Your answer
Physical Limitations or Impairments *
Your answer
Highly Preferred Toys, Activities, Reinforcement, Etc. *
Your answer
Sensory Precautions *
Your answer
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