New Client Intake Form (Orthopedics)

*Required fields are noted with an asterisk.

Patient Name

First Name

Last Name

Sex

Female

Male

Age/Date of Birth

Parents'/Guardians' Names

Address

Phone

(###)

###

####

Referring physician

PCP (if different)

Specialists (Name and specialty)

Diagnosis / main concern

When did symptoms start (onset)

How would you describe your child’s gross motor functioning in their environment ? (indoors, outdoors, playground, school, etc)

Does your child play competitive/recreational sports

Hand dominance

Right

Left

Not sure

Equipment/orthoses

Did/does your child receive any other services? (Early Intervention, PT, OT, SP, Special instruction, play therapy, etc.)

Other information

I certify that this information is true and correct to the best of my knowledge. I will notify my therapist of any changes in the above information within 30 days.

Name

Date

YYYY

Relationship to patient