Pediatric Physical Therapy, LLC - General Information & Medical History Form

Sep 19, 2026

Upload by Elsa

General Information & Medical History Form for pediatric patient intake at Pediatric Physical Therapy, LLC. Captures patient demographics and primary contact details, guarantor (parent/guardian) information, and insurance coverage including Medicaid data. Collects child’s medical diagnosis overview, allergies, physician history, current and past medical conditions, family medical history, surgeries, medications, diagnostic tests, birth and postnatal history, developmental milestones, and social history. Includes eating habits, daily equipment, and therapist review of systems.

LanguageEnglish

CategoryForms

FormatPDF

Pages10

Reading Time4 min

AccessFree to download

Patient Information

Primary Contact

Guarantor Information

Insurance Information

General Information & Medical History Form

Allergies

Physician and Diagnostic History

Current Symptoms and Diagnoses

Family Medical History

Birth History

Postnatal History

Milestones

Social History

Review of Systems

Pediatric Physical Therapy, LLC 881 Hillcrest Rd Mobile, AL 36695 Patient Information Name Sex Race Date ofBirth Social Security Number Address City, State, Zip Primary Contact Name Relationship To Patient Date ofBirth SS\# Address City, State, Zip Phone Employer Work Phone Primary Email: Who to Notify upon Emergency – Secondary Contact Name Relationship To Patient Date ofBirth Address City, State, Zip Phone Employer Work Phone Guarantor Information –(PARENTS OR GUARDIAN) Name Relationship Date ofBirth Social Security Number DL Number Address City, State, Zip Phone Work Phone Employer Employers Address Occupation Insurance Information Insured Person Name Relationship to Patient Date ofBirth Social Security Number Phone Number Primary Insurance Phone Number Policy Number Group Number Employer Employers Address Work Number Secondary Insurance Phone Number Policy Number Group Number Employer Work AL Medicaid Information Name as it Appears on Medicaid Card Medicaid Number Pediatric Physical Therapy, LLC 881 Hillcrest Rd Mobile, AL 36695 General Information & Medical History Form Child's Name Date ofBirth Sex Address City, State, Zip Home Phone Number Daytime Number Referring Physician Medical Diagnosis Mother's Name Father's Name School Grade Height Weight Allergies: • Allergies to Medications: • Latex: Yes No Peanut: Yes No Other: Yes No • Do you carry an Epi Pen for any of these allergies? Yes No • Other Allergies Please list all physicians who care for your child Date Last Seen 1. 2. 3. 4. 5. Has your child recently experienced any of the following? Yes Yes Yes Yes Yes Yes No No No No No No Weight loss or gain Nausea / Vomiting / Diarrhea Fatigue Unusual Weakness Fever / Chills / Sweats Numbness / Tingling Has your child EVER been diagnosed as having any of the following? Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No Cancer Heart Problems High Blood Pressure Asthma / Breathing Problems Thyroid Problems Diabetes Arthritis Depression Hepatitis 3 Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No Tuberculosis Stroke Kidney Disease Anemia Epilepsy Seizures Cerebral Palsy Muscular Dystrophy Spina Bifida ADD/ADHD Other List all surgeries, injuries, and hospitalizations List all medications and dosages the child is currently taking List all over the counter medications your child takes List any recent Diagnostic Tests and the results: (MRI, CT scan, X-rays, Lab Work) | | | --- | | | | | | | Has anyone in the child's immediate family (parents, brothers, sisters) been treated for any of the following? Yes No Diabetes Yes No Tuberculosis Yes No Heart Disease Yes No High Blood Pressure Yes No Asthma / Breathing Problems Yes No Stroke Yes No Kidney Disease Yes No Cancer Yes No Arthritis Yes No Anemia Yes No Headaches Yes No Epilepsy / Seizures Yes No Mental Illness Yes No Alcohol or Chemical Dependency Birth History Complications during pregnancy? Yes No If yes, please specify. Premature Delivery Yes No If yes, how many weeks? Birth weight Mode of delivery Immediate respiration? Yes No If no, please infer how long before respiration and or medical interventions required. Complications during/after delivery? NICU stay required Yes No If yes, how long? Other Postnatal History Please list and describe any important injuries or illnesses that are not already listed including ear and chest infections (also indicate if hospitalization was required for any of these illnesses) . At what ages did these occur? Milestones Roll over Cruise, walk with support Sit alone Walk a

FAQs

What information is requested for the patient and primary contact?

The form asks for the child’s name, date of birth, sex, and address details, plus the primary contact’s name, relationship, contact information, and employer details.

How does the form collect allergy and medication history?

It includes sections for allergies to medications and substances (e.g., latex/peanut/other), whether an Epi Pen is carried, and lists of all current medications, over-the-counter medications, and related dosages.

What medical history topics are covered beyond the child’s own conditions?

It collects family medical history for immediate family members, birth and postnatal history, developmental milestones, and a review of systems by marking current symptoms.

Sep 19, 2026

Upload by Elsa