PHYSICAL THERAPY BRIEF ADMISSIONS FORM

Child Information

Child’s Name

Goes By

DOB

Please enter a date that isn't in the future.

Gender

Male

Female

Diagnosis

Evaluation Concerns and Current Services

Medical History

Function and Development

Does your child use any specialized equipment (hearing aids, eyeglasses, wheelchair, walker, foot orthotics)?

How does your child best communicate? Verbal (single words, phrases, sentences) or non-verbal (body language, facial expressions, pointing/gestures, AAC device, sign language)?

Favorite toys/play activities:

Do you have any concerns regarding your child’s sensory processing/regulation (touch, sights, sounds, body awareness, balance, social participation)? If so, please explain.

Milestone — When (in months)

Holds head up alone

Sit alone, no support

Rolling

Pull to stand

Creep/crawl

Walk unaided

How does child get around the house?

How does your child do with gross motor/balance activities? Any assistance needed?

Crawling on hands and knees:

Walking:

Jumping:

Stairs:

Balance (balance beams, standing on 1 foot, etc.):

Is your child involved in any extracurricular activities, and what are they?

Parent Signature

Thank you for this information related to your concerns as they relate to physical therapy. This allows your evaluating therapist to select the most appropriate assessment tool(s) for your child.

Parent Signature

Date

PHYSICAL THERAPY BRIEF ADMISSIONS FORM

Child Information

Evaluation Concerns and Current Services

Current therapy services your child is receiving:

Medical History

Hearing Test

Vision Test

Contraindications/Precautions:

Function and Development

Milestone — When (in months)

Parent Signature