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The document requests detailed background to help the physical therapist understand the child’s health and family needs, including referral information, diagnoses and diagnosis age, medications, precautions and allergies, and other healthcare providers. It also collects therapy history, current services, primary areas of concern, PT goals and functional activities, pain details, equipment/orthotic history, and social and behavioral history for the child.",{"@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/physical-therapy-intake-form-1/307749/",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/physical-therapy-intake-form-1/307749.png","ImageObject",442,249,{"name":88,"@type":89},"Graffin","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",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What should parents/guardians do before the child’s initial physical therapy exam?","Question",{"text":109,"@type":110},"Fill out the entire intake form before coming to the initial therapy examination to avoid delaying treatment. Provide as much detail as possible so the physical therapist can understand the child’s health and the family’s needs.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What medical information is requested on the form?",{"text":114,"@type":110},"The form asks for current medical or orthopedic diagnoses, how old the child was at diagnosis, current medications and dosing schedule, and any medical precautions, allergies, and related reactions. It also requests a copy of the PT referral from the doctor.",{"name":116,"@type":107,"acceptedAnswer":117},"How does the form collect therapy history and current services?",{"text":118,"@type":110},"It asks whether occupational, physical, or speech therapy previously ended, including the child’s age, the reason, and the results. 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In order not to delay treatment, please fill out the entire intake form and provide as much detail as you can to better help the physical therapist understand your child and the needs of the family.  \nIt is helpful for parents to fill out this information ahead of time so they can think carefully about the answers. History taking without a health history form can be difficult at the first appointment as children often are very eager to play and have a hard time sitting still while parents answer many questions. Of course, your therapist will still speak with you regarding your child’s history. This form is simply designed to speed up the process and insure that your child’s therapist has a complete understanding of your child’s health. Furthermore, we strongly encourage you to bring copies of any pertinent medical or school records (i.e. IEP, evals, etc.) to your child’s initial examination.  \nThank you for choosing us for your child's therapy needs.  \nSincerely,  \nNantesha Chen, PT, DPT  \nPhysical therapist  \nPhysical therapy Intake form 1  \nPhysical therapy Pediatric intake form  \nChild’s name:   DOB:  Age:   qM q F Parent(s)/Guardian’s name:   Relationship to child:   Occupation of Parent/Guardian:   Home Address:    \n\n| Are there stairs to get into the home or in the home? qYes q No If yes, how many flights   Who referred you to physical therapy? Full name of referring doctor and their contact information. |\n| --- |\n| Reason for PT referral: Please include a copy of the PT referral from doctor. |\n\nCurrent medical or orthopedic diagnosis: Provided by the referring doctor (include any diagnosis provided: ie: ASD, ADHD, speech delay, motor developmental delay, brachial plexus injury, gait abnormality, hip dysplasia, CP, etc.) How old were they when they received the diagnosis?  \nPlease list current medications and what they are for: When do they take it, how many times a day?  \nPlease list any medical precautions or allergies and reactions:  \nPhysical therapy Intake form 2  \nOther Doctors and healthcare providers involved in your child’s care: (ie neurologist, cardiologist etc) List reason they are seeing them. How often do they see these doctors and when is next appointment?  \nHas your child previously received occupational, physical, or speech therapy that has ended? How old was your child and what reason were they going? What were the results? When and WHY did the services  \nend? If your child still receives these services today, then skip to next question.  \nIs your child currently receiving any of these therapy services? Check ALL that apply.  \nLIST locations, and frequency (how many times a week for each service), how old was your child when they started to receive these services?  \n☐ Speech therapy  \n☐ Occupational therapy  \n☐ Physical therapy  \n☐ Psychological services  \n☐ Behavioral therapy  \n☐ ABA  \n☐ Early intervention  \n☐ Hearing services ☐ Vision services  \n☐ Assistive technology services  \n☐ orientation and mobility services ☐ Other  \nWhat are your primary areas of concern? What are you hoping for the physical therapist to address? Please check off all that apply and explain in detail below and give examples:  \n􀀀 Balance  \n􀀀 Coordination  \n􀀀 Endurance  \n􀀀 Posture  \n􀀀 Delayed milestones  \n􀀀 Upper body strength  \n􀀀 Lower body strength  \n􀀀 Overall weakness  \n􀀀 Muscle tightness  \n􀀀 Joint laxity (looseness)  \n􀀀 Safety awareness  \n􀀀 Body awareness  \n􀀀 Equipment Adaptations  \n􀀀 Gait (how they walk)  \n􀀀 Other  \nPhysical therapy Intake form 3  \nPlease list the goals you would like physical therapy to work on? List functional activities (age appropriate activities your child is having difficulty with or you are concerned with).  \nThis is what your child has difficulty doing (activity) that PT can help with.  \nThis is a small list of examples; please list accordin","cbCaieffT7zsNtgO","https://ap.wps.com/l/cbCaieffT7zsNtgO","pdf",205154,8,"English","# Physical therapy intake form\n## Parent/guardian instructions\n## Child and referral information\n## Medical history and diagnoses\n## Medications, precautions, allergies\n## Other healthcare providers\n## Prior and current therapy services\n## Areas of concern and PT goals\n## Pain history\n## Equipment and orthotic history\n## Social history\n## Behavioral history","[{\"question\":\"What should parents/guardians do before the child’s initial physical therapy exam?\",\"answer\":\"Fill out the entire intake form before coming to the initial therapy examination to avoid delaying treatment. Provide as much detail as possible so the physical therapist can understand the child’s health and the family’s needs.\"},{\"question\":\"What medical information is requested on the form?\",\"answer\":\"The form asks for current medical or orthopedic diagnoses, how old the child was at diagnosis, current medications and dosing schedule, and any medical precautions, allergies, and related reactions. It also requests a copy of the PT referral from the doctor.\"},{\"question\":\"How does the form collect therapy history and current services?\",\"answer\":\"It asks whether occupational, physical, or speech therapy previously ended, including the child’s age, the reason, and the results. It also asks whether the child is currently receiving related services and collects locations and weekly frequency for each service.\"}]","Physical Therapy Intake Form - 1 | PDF",1789854453]