Medical History Form – Pediatric Therapy Services

Office Location*

Please select your correct location for each form.

Patient First Name*

Patient Last Name*

Email*

Birthdate*

Primary Care Pediatrician Full Name

Phone Number

Address

Zip Code

Patient's Specialists (list all):

Are there any changes in your doctors?

If yes, please list:

Any changes or additions to diagnosis?

If yes, please list:

Please list your current medication(s) using the following format: Name/ Dose/ Frequency/ Purpose/ Method

Method choices might include: PO, IV, NG, Nebulizer, Aerosol.

List child's equipment:

School, Daycare or Preschool child attends:

Grade:

Other outside therapy?

If yes, name of provider:

Frequency of each:

In school setting?

Frequency:

PROVIDE MOST CURRENT EVALUATIONS FROM PROVIDER.

Does child require special diet/restrictions?

If yes, please list:

Areas of concern:

Safety issues:

Therapy goals?

The information above has been completed to the best of my knowledge and ability.

Full Name

Relationship to Patient:*

Signature*

Date*