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Alexandra Buwalda DPT, PCS
About
Background
Approach
Services
Services
Referrals
Testimonials
Forms
Contact
Client Intake Form (Orthopedics)
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
*
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
*
Left
Right
Not sure
Equipment/orthoses
*
Did/does your child receive any other services? (Early Intervention, PT, OT, ST, Special instruction, play therapy, etc.)
*
Please list any other information you would like me to know.
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
*
MM
DD
YYYY
Thank you!