Pediatric Medical History Form | Therapy SPOT

Pediatric Medical History

Please provide us with your child's medical history so that we may be better prepared to work with you at your first appointment. This is a secure page and any information you complete with be stored safely in your medical file. If you would prefer to complete this form in person, please print this page and bring it with you for your appointment. Alternatively, you can arrive 15 minutes prior to your appointment and you can complete this form in our office. We will have follow-up questions for you regarding your medical history.

Step 1 of 7

14%

Name(Required)

First Last

Patient Date of Birth(Required)

Month

Day

Year

Please provide the patients birthday to allow us to check medical insurance benefits

Gender

Male

Female

Prefer Not to Answer

Reason for referral

Referred by

When did you first have these concerns?

Does your child have a diagnosis?(Required)

Yes

Diagnosis

Name of Doctor who provided the diagnosis:

Medical History

Length of pregnancy

Any difficulties during pregnancy/delivery?

Yes

Please Specify

Did your child require assistance to start breathing after birth?

Yes

Was NICU required for breathing difficulties?

Yes

Did your child experience feeding difficulties in early infancy?

Yes

Was NICU required for feeding difficulties?

Yes

Did/does your child have frequent ear infections?

Yes

Were tubes placed?

Yes

When were the tubes placed?

Has your child had any hospitalizations, serious illnesses/injuries, or surgeries since birth?

Yes

Please Specify

Has your child had any x-rays, diagnostic tests, or genetic screens?

Yes

Please Specify

Does your child use any specialized equipment?

Yes

Please Specify

Does your child take medication on a regular basis?

Yes

Please list medications

Developmental History

Has your child met gross and fine motor milestones at an expected age?

Yes

Please Specify

Has your child met speech and language milestones at an expected age?

Yes

Please Specify

Do you have concerns regarding your child's self-help skills?

Yes

Please Specify

Do you have concerns regarding your child's eating/feeding skills?

Yes

Please Specify

Do you have concerns regarding your child's emotional regulation?

Yes

Please Specify

Do you have concerns regarding your child's ability to learn new skills?

Yes

Please Specify

Social and School History

With whom does the child live?

Is your child in school?

Yes

Name of School

Grade

Has the teacher shared any concerns?

Yes

Please Specify

Is your child currently receiving therapies?

If so, please check all that apply

Occupational Therapy

Physical Therapy

Speech Therapy

Psychology / Social Work

ABA/ Behavioral Therapy

Educational / IEP

Vision Therapy

Auditory Therapy

None

Has your child received occupational therapy, physical therapy, or speech therapy in the past (if different from present therapy history)?

If so, please check all that apply

Occupational Therapy

Physical Therapy

Speech Therapy

Psychologist / Social Work

ABA/ Behavioral Therapy

Educational / IEP

Vision Therapy

Auditory Therapy

None

What are your primary goals for this evaluation?

Is there any other information that would assist us in your child's care?

Consent(Required)

CONSENT:

1. I consent to participate in physical therapy services at STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC. I acknowledge that participation in physical exercise and rehabilitation may involve the use of exercise equipment and devices and poses potential risks of bodily injury or death.

2. I hereby accept the responsibility for any harm, injury, or damage that may result from my participation in physical exercise and/or training. I hereby waive, release, absolve, indemnify, and agree to hold harmless STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC, its officers, employees, and affiliates for any claim arising out of any injury to me as a result of negligence or any cause. I voluntarily and knowingly acknowledge, accept, and assume these risks.

3. I understand that the practice of physical therapy, although strong efforts are made to utilize best practice, is not an exact science and that no guarantees or promises have been made to me as a result of treatments or examinations by the physical therapist or supportive personnel. I understand that no contract, warranty, guarantee, or promise concerning the results of physical therapy services is made.

RELEASE OF INFORMATION:

1. STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC releases patient health care information for purposes of treatment or payment, or to other health care organizations as outlined in our “Notice of Privacy Practices.” I authorize the release of any medical, financial, or other information pertinent to my case to any insurance company, adjuster, attorney, or third-party payer involved in this case for the purpose of processing claims and securing payment of benefits.

2. I have read the “Notice of Privacy Practices” and understand that a copy of the notice will be provided to me upon my request.

INSURANCE and PAYMENT:

1. I authorize the staff at STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC to obtain and review my health insurance coverage in the manner that it is available from my insurance company.

2. I understand that my insurance benefits are only a quote of benefits and are not a guarantee of payment. I understand that it is my responsibility as a patient to know my insurance coverage and that insurance coverage is an arrangement between the carrier and the patient.

3. I acknowledge that I will be ultimately responsible for payment of services rendered at this facility. I agree to pay in full any and all charges not covered by insurance or other benefits. I understand that it is unlawful to waive copays, co- insurance, and deductibles that are my responsibility.

4. I authorize payment to be made from my insurance company directly to STAR Spine Therapy & Amputee Rehabilitation, PLLC, Therapy SPOT - Bellaire, and/or Associates of Physical Therapy Specialists, PLLC for services rendered.

5. I agree to pay my bill at the time of service unless other arrangements have been made with the Billing Department.

6. There will be a fee of $45.00 for any returned checks.

7. I understand that if my financial arrangement is not fulfilled as agreed, my account will be transferred to an outside agency to assist in collecting the remaining balance. A 35% fee will be added to the unpaid balance and will be my financial responsibility.

8. Medicare patients: Please see attached “Notice to Medicare Patients.”

LATE/CANCELLATION/NO SHOW POLICY:

1. Please make every effort to be on time for your appointment. If you show up late, your therapist may not have the time to treat you, or your therapy time may be reduced. Please call the office if you know that you will be late. You may be asked to reschedule your appointment.

2. If you must change or cancel your appointment, please call 24 hours in advance. Same day cancellations and no-show appointments are liable to a $45.00 charge to your account.

3. I understand that it is my responsibility to keep track of my scheduled appointments. I understand that it is a courtesy of the office to send me a patient appointment reminder. I will contact the office with any questions regarding my schedule.

4. If you have 3 consecutive last minute cancellations or no-show appointments, we will have to remove your recurring appointments from our calendar. Consistent no-shows will result in the termination of the therapist/patient relationship.

I agree

Signature

CAPTCHA

Call Us

Email Us