CHILD'S NAME: _______________________________________________M: _____ F: ____
DATE OF BIRTH: ________________________ AGE: _______________________________
PARENT / GUARDIAN NAME: __________________________________________________
ADDRESS: ___________________________________________________________________
_____________________________________________________________________________
PHONE: HOME (_____)____________________ WORK (______)___________________
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__________________________________________________________
PLEASE PROVIDE PHONE NUMBERS TO ALL SPECIALISTS WHO TREAT YOUR CHILD
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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 THERAPY AT EUROPEDS OR EUROMED CLINIC ?
( IF YES PLEASE EXPLAIN WHEN AND WHY )
_______________________________________________________________________________
_______________________________________________________________________________
12. PLEASE PROVIDE US WITH WRITTEN HIP X-RAY REPORT (NO OLDER THAN 6 MONTHS)
PLEASE MAIL OR FAX COMPLETED FORM TO:
Therasuit LLC
Pediatric Fitness Center
2111 Cass Lake Rd., Suite 102
Keego Harbor, MI 48320
Phone 248-706-1308
Fax 248-706-1049
suittherapy@aol.com