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ONLINE MEMBER HEALTH APPLICATION FORM 

CHILD'S  NAME: 
 SEX: 
DATE OF BIRTH: 
PARENT / GUARDIAN NAME:
ADDRESS:   
PHONE: HOME 
FAX:     
E- mail:      
 

 
1. WHAT IS THE CHILD’S DIAGNOSIS:
 

 
2. GIVE  MEDICAL / SURGICAL HISTORY: 
- HISTORY OF BOTOX/PHENOL INJECTIONS
- HISTORY OF INHIBITIVE / SERIAL CASTING  (DATES)
- HISTORY OF FRACTURES  
 

 
3. WHAT IS THE CHILD'S:
- HEIGHT 
- WEIGHT 
 

 
4. CIRCUMFERENCES OF:
CHEST
WAIST 
 THIGH 
 

 
5. MEDICAL STATUS
- SEIZURES (date of last one)
- SCOLIOSIS
- HEART PROBLEMS / HYPERTENSION / PAST HEART SURGERIES
- LUNGS PROBLEMS
- DIABETES     
- VISION/HEARING    
- SHUNTS (hydrocephalus)
- TRACHEAL/G- TUBE   
- KIDNEY PROBLEMS
 

 
  6. PLEASE LIST ANY MEDICATIONS YOUR CHILD IS CURRENTLY TAKING (and reason for taking)
 

 
7. CHILD ABILITIES (rolling, sitting, crawling, and walking):
 

 
8. LIST OF MEDICAL EQUIPMENT THAT YOUR CHILD IS USING:
    (braces, walker, crutches, wheelchair) 
 

 
9. HOW DO YOU COMMUNICATE WITH YOUR CHILD / HOW DO THEY COMMUNICATE WITH YOU ?
 

 
10. IS YOUR CHILD ABLE TO FOLLOW SIMPLE COMMANDS:
 

 
11. HAVE YOU EVER BEEN  DENIED SUIT THERAPY?
       ( IF YES PLEASE EXPLAIN WHERE, WHEN AND WHY )
 

 
12. PLEASE PROVIDE US WITH  WRITTEN HIP X-RAY REPORT  (NO OLDER THAN 6 MONTHS)

                                                                                                                                           

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