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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.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/pediatric-physical-therapy-llc-general-information-medical-history-form/307752/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/pediatric-physical-therapy-llc-general-information-medical-history-form/307752.png","ImageObject",442,249,{"name":88,"@type":89},"Elsa","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",20,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is requested for the patient and primary contact?","Question",{"text":109,"@type":110},"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.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form collect allergy and medication history?",{"text":114,"@type":110},"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.",{"name":116,"@type":107,"acceptedAnswer":117},"What medical history topics are covered beyond the child’s own conditions?",{"text":118,"@type":110},"It collects family medical history for immediate family members, birth and postnatal history, developmental milestones, and a review of systems by marking current symptoms.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307752,1790245168,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":79},137455077381,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Pediatric Physical Therapy, LLC  \n881 Hillcrest Rd  \nMobile, AL 36695  \nPatient Information  \nName   Sex   Race  Date ofBirth   Social Security Number   Address   City, State, Zip    \nPrimary Contact  \nName   Relationship To Patient   Date ofBirth  SS\\#  Address   City, State, Zip   Phone   Employer   Work Phone    \nPrimary Email:   \nWho to Notify upon Emergency – Secondary Contact  \nName   Relationship To Patient   Date ofBirth   Address   City, State, Zip   Phone   Employer   Work Phone    \nGuarantor Information –(PARENTS OR GUARDIAN)  \nName   Relationship   Date ofBirth   Social Security Number   DL Number   Address   City, State, Zip   Phone   Work Phone   Employer    \nEmployers Address   Occupation    \nInsurance Information  \nInsured Person Name  Relationship to Patient   Date ofBirth   Social Security Number   Phone Number    \nPrimary Insurance   Phone Number   Policy Number   Group Number   Employer    \nEmployers Address   Work Number   \nSecondary Insurance   Phone Number   Policy Number   Group Number   Employer   Work   \nAL Medicaid Information  \nName as it Appears on Medicaid Card    \nMedicaid Number    \nPediatric Physical Therapy, LLC  \n881 Hillcrest Rd  \nMobile, AL 36695  \nGeneral Information & Medical History Form  \nChild's Name   Date ofBirth   Sex    \nAddress   City, State, Zip   Home Phone Number   Daytime Number   Referring Physician   Medical Diagnosis   Mother's Name   Father's Name   School   Grade   Height   Weight    \nAllergies:  \n• Allergies to Medications:    \n• Latex: Yes No Peanut: Yes No Other: Yes No  \n• Do you carry an Epi Pen for any of these allergies? Yes No  \n• Other Allergies    \nPlease list all physicians who care for your child Date Last Seen  \n1.      \n2.      \n3.      \n4.      \n5.      \nHas your child recently experienced any of the following?  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nWeight loss or gain Nausea / Vomiting / Diarrhea Fatigue  \nUnusual Weakness  \nFever / Chills / Sweats Numbness / Tingling  \nHas your child EVER been diagnosed as having any of the following?  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nCancer  \nHeart Problems  \nHigh Blood Pressure Asthma / Breathing Problems Thyroid Problems  \nDiabetes Arthritis Depression Hepatitis  \n3  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nYes  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nNo  \nTuberculosis Stroke Kidney Disease Anemia Epilepsy Seizures Cerebral Palsy  \nMuscular Dystrophy Spina Bifida ADD/ADHD  \nOther    \nList all surgeries, injuries, and hospitalizations  \nList all medications and dosages the child is currently taking  \nList all over the counter medications your child takes  \nList any recent Diagnostic Tests and the results: (MRI, CT scan, X-rays, Lab Work)  \n\n|  |\n| --- |\n|  |\n|  |\n|  |\n\nHas anyone in the child's immediate family (parents, brothers, sisters) been treated for any of the following?  \nYes No Diabetes  \nYes No Tuberculosis  \nYes No Heart Disease  \nYes No High Blood Pressure Yes No Asthma / Breathing Problems  \nYes No Stroke  \nYes No Kidney Disease  \nYes No Cancer  \nYes No Arthritis  \nYes No Anemia  \nYes No Headaches  \nYes No Epilepsy / Seizures Yes No Mental Illness  \nYes No Alcohol or Chemical Dependency  \nBirth History  \nComplications during pregnancy? Yes No If yes, please specify.  \nPremature 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    \nPostnatal History  \nPlease 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?  \nMilestones  \nRoll over   Cruise, walk with support    \nSit alone   Walk a","cbCaidyZnGWeiTni","https://ap.wps.com/l/cbCaidyZnGWeiTni","pdf",122412,10,"English","# Patient Information\n# Primary Contact\n# Guarantor Information\n# Insurance Information\n# General Information & Medical History Form\n## Allergies\n## Physician and Diagnostic History\n## Current Symptoms and Diagnoses\n## Family Medical History\n## Birth History\n## Postnatal History\n## Milestones\n## Social History\n## Review of Systems","[{\"question\":\"What information is requested for the patient and primary contact?\",\"answer\":\"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.\"},{\"question\":\"How does the form collect allergy and medication history?\",\"answer\":\"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.\"},{\"question\":\"What medical history topics are covered beyond the child’s own conditions?\",\"answer\":\"It collects family medical history for immediate family members, birth and postnatal history, developmental milestones, and a review of systems by marking current symptoms.\"}]","Pediatric Physical Therapy, LLC - General Information & Medical History Form | PDF",1789854459]