Date:
PATIENT'S NAME (LAST, FIRST)
DATE OF BIRTH
MALE
FEMALE
STREET ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE NUMBER
EMAIL ADDRESS FOR RECEIPTS
PARENT'S/GUARDIAN'S NAME
DATE OF BIRTH
CELL PHONE NUMBER
SOCIAL SECURITY NUMBER
EMPLOYER
POSITION
PHONE NUMBER
RELATIONSHIP TO PATIENT
PARENTS'S/GUARDIAN'S NAME
DATE OF BIRTH
CELL PHONE NUMBER
SOCIAL SECURITY NUMBER
EMPLOYER
POSITION
PHONE NUMBER
RELATIONSHIP TO PATIENT
PRIMARY CARE PHYSICIAN
PHONE NUMBER
REFERING PHYSICIAN
PHONE NUMBER
DO YOU HAVE A PERSCRIPTION?
Yes
No
Parent/Guardian Marital Status:
Single
Married
Separated
Divorced
Other
Child lives with (check one):
Birth Parents
Foster Parents
One Parent
Adoptive Parents
Parent and Step Parent
Other
Child’s race/ethnic group:
Caucasian, Non-Hispanic
Asian or Pacific Islander
African-American/Black
Native American
Hispanic
Other
Is there a language other than English spoken in the home?
Yes
No
If yes, which one?
How did you hear about us?
Describe your child’s strong likes:
Describe your child’s strong dislikes:
What is your child’s favorite toy/activity/interests?
Patient’s preferred name if any?
Insurance Information
- Attach a photo of the front and back of the insurance card.
Front:
Back:
Primary Insurance Name:
Subscriber’s Name:
ID#:
Group#
Phone #:
Secondary Insurance Name:
Subscriber’s Name:
ID#:
Group#
Phone #:
PATIENT’S NAME:
DATE OF BIRTH:
What is your chief complaint?
Please mark the location of your pain on the figures below.
Right
Left
Right
Left
How would you describe your pain? Check all that apply:
Sharp
Aching
Dull
Shooting
Cramping
Throbbing
Stiffness
Burning
Radiating
Tingling
Numb
How does your pain change over time?
Continuous
Frequent
Occasionally
Intermittent
On the numerical scale below, rate your pain:
Pain at WORST:
Pain at BEST:
Pain TODAY:
0
1
2
3
4
5
6
7
8
9
10
What makes your pain worse?
What makes your pain better?
PATIENT’S NAME:
DATE OF BIRTH:
Date of injury or when the pain began:
How did the problem begin? (Injury, fall, motor vehicle accident, sports, etc.)
Have you had any diagnostic tests for this problem? (X-ray, MRI, CT scan, etc.)
Which activities are more difficult since this problem began? Check all that apply:
Personal care
Walking
Getting in/out of bed
Exercising
Standing
Sleeping
Driving
Sitting
Concentrating
Recreational activities / sports / gym class
Bending
Working / chores
Lifting
Other
What types of activities / hobbies / exercises do you regularly perform and how often?
List any surgeries and dates:
Do you have any other pertinent medical history or diagnoses?
Please list any medications your child (please include purpose of the medication)?
Does your child have any known allergies to food or to the environment?
Yes
No
If yes, please list
What are your goals for therapy?
PATIENT’S NAME:
DATE OF BIRTH:
PHOTO PERSMISSION
1. I give permission for photographs/videotape of my child for the purpose of treatment, education, and documentation.
Initial
2. I give permission for photographs/videotape of my child for website/Facebook.
Initial
Notice of Privacy Practices (HIPAA Acknowledgement/Consent)
I hereby acknowledge receipt of the Notice of Privacy Practices for ABC Pediatric Therapy, LLC. I hereby consent to the use and disclosure of my child’s protected health information (PHI) for the purpose of evaluation, treatment, payment, and health care coordination.
Initial
Thank you for your time in filling out this information regarding your child.
Completed by:
Relationship:
Date:
Attach a photo of your driver's license: