Pediatric Physical Therapy Intake Form
Patient Information
Child’s Full Name
Date of Birth
Age
Gender
Male
Female
Other
Home Address
Parent/Guardian Name
Phone Number
Email Address
Relationship to Patient
Referral and Medical History
Referred By
Reason for Visit/Current Concerns
Medical Diagnosis (if any)
Current Medications
Known Allergies
Relevant Medical History
Developmental History
Pregnancy/Birth History
Developmental Milestones (e.g., rolling, sitting, crawling, walking)
Previous Therapies/Interventions
Social and Educational Information
School/Daycare
Grade/Program
Social/Behavioral Concerns
Interests/Strengths