Physical Therapy Intake Form Parent or Guardian's First Name* Parent or Guardian's Last Name* Phone Number*Email Address* Child's Name* DOB* Month Day Year Current Diagnoses: What are your primary areas of concern?What are your goals for therapy?Please list any medical precautions:Please list any significant illness, hospitalization, or surgery: Please check all that apply, and describe your concerns about your child. Gross Motor: Difficulty with jumping, skipping, running, hopping Difficulty kicking a ball Difficulty throwing and/or catching a ball Appears weaker than peers, fatigues easily Avoids or has difficulty playing on playground equipment Appears stiff or awkward during movement Clumsy, decreased awareness of body in space, bumps into objects and people Difficulty coordinating two sides of the body Poor posture, frequently leans into things Awkward gait, unsteady walking, toe walking, drags feet Difficulty negotiating the stairs Concerns: Fine Motor: Difficulty with drawing, coloring, tracing Avoids drawing, coloring, tracing and/or writing Problem holding writing tools (grasp too lose, tight or awkward) Writing is too dark, light, large, or small Switches hands frequently, appears to have no dominant hand Slow in completing table top tasks Poor posture while sitting in a chair, leans into desk, fidgets Difficulty using classroom tools such as scissors and glue Shifts body rather than rotating across midline Concerns:Does your child have trouble keeping up with peers during physical play? Yes No If yes, please explain. Does your child participate in any extra-curricular activities? Yes No If yes, please list all activities.