InstagramThis field is for validation purposes and should be left unchanged.Pediatric Orthopedic Physical Therapy History FormPatient's NameGenderD.O.B. MM slash DD slash YYYY Parent/CaregiverTelephoneEmail Referring PhysicianAllergiesMedicationsHeightWeightSchool & GradeRecreational / Sports ActivitiesPrimary Reason for VisitDate of Injury & History of Current ConditionHave you received therapy in the last 12 months?Chiropractic Care or X-Ray?Conditions Asthma Anxiety Cancer Bladder Incontinence Bowel Incontinence Scoliosis Joint Pain Depression / Mental Health Seizure Disorder Sleeping Disorder Prior Surgeries Prior SurgeriesTypeDate Add RemovePrior InjuriesTypeDate Add RemoveOtherPrior to this injury, has your child been diagnosed with any developmental delays or motor disorders (if yes, please explain)Pain Level:Pain Level:Pain at Best in the last 5 daysPlease enter a number from 0 to 10.Pain at Worst in the last 5 daysPlease enter a number from 0 to 10.What helps with your pain Ice Heat Medication Please check if you are limited in any of the following: Sitting for extended periods Standing for extended periods Repetitive bending Lifting moderate weights Lifting heavy weights Walking Running Typing / Computer operation Please mark the image for areas with symptoms of pain, numbness or tingling List the areas with symptoms below: Add RemoveI authorize the therapists of Valley Kids Therapy to administer treatment as proscribed and considered therapeutically necessary on the findings during the course of the assessment.Name(Required)Signature(Required)CAPTCHA
