Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Toe walking intake form - Early Intervention Associates
Document related concepts
Transcript
Early Intervention Associates Pediatric Physical Therapists 6208 Montrose Road Rockville, Maryland 20852 Phone 301 468 9343 Fax 301 230 2127 New Patient Intake Form – Toe Walking Today’s Date:____________ Demographics: Child’s Name: ___________________________________ Child’s DOB:_____________ School/Child Care Center attending (if applicable):_______________________________ Nanny/Caretaker name (if attending sessions): __________________________________ Background on today’s visit: 1. What concerns led you to bring your child for a PT evaluation? 2. What concerns does your child’s doctor/teacher/child care provider have, if any? 3. Please describe any previous or current physical therapy received in terms of time frame, benefits, and/or challenges. 4. Please describe any previous, or current therapy services in any other disciplines (i.e. occupational therapy, speech therapy, mental health services, vision therapy, etc) which you feel are relevant to today’s visit. 5. How would you describe your goals for your child related to physical therapy? Child’s Name: _________________________ Medical History: 1. Current Medical Diagnosis, if any:__________________________________________ 2. Current Medications, if any:_______________________________________________ 3. Birth history: ___ Term ____ Preterm ____birth weight ____C-section ___ vaginal delivery 4. Medical History: Please check off any current or previous concerns in any of the following areas, and explain below as needed to provide a comprehensive look at your child’s medical history. __ Birth complications __chronic ear infections and/or ear tubes ___NICU stay __ER visits __vision concerns __head injury __hearing concerns __ hospitalizations __ genetic disorder __surgeries __ seizures __car sickness __neurological concerns __allergies __ autism __behavioral concerns __delayed language skills __torticollis __ toe walking Please explain: Developmental history and walking 1. Age when child walked independently? ________________(months) 2. Is your child having difficulties with learning or attention? yes____ no_____ 3. Has your child always walked on his or her toes? yes____ no______ If not, at what age did toe-walking begin? ______________(months) 4. Is your child able to heel-toe walk sometimes? yes____ no_____ Partially adapted from: Clark E, Sweeney JK, Yocum A, McCoy SW. Effects of motor control intervention for children with idiopathic toe walking: a 5-case series. Pediatr Phys Ther. 2010;22(4):417-26. Child’s Name: _________________________ 5. On the following line please mark your estimate how much toe-walking your child engages in at this time: [_____________________________________________________________] 0% 6. 10 20 30 40 50 60 70 80 90 100% Check problems or your concerns about your child as a result of toe-walking: ____falling* ____feet turn in (pigeon toe) ____poor balance ____feet turn out ____tight calf muscles ____leg or foot pain ____tires easily ____flat foot, no arches ____limps ____knee problems ____bunion ____teased by other children *How often does your child fall?__________________________________ Are there particular circumstances in which your child is more likely to fall? _____________________________________________________________ 7. Have you made any efforts to change your child’s walking? yes____ no_____ If so, what happened as a result of your efforts?_________________________________ 8. Does your child’s toe-walking behavior vary with the time of day? yes___ no____ 9. Are there any more details about your child’s walking that you would like to add?_________________________________________________________________ Family history related to toe-walking 1. Please list any immediate or extended family members who were “toe walkers” after the age of 3 years_______________________________________________________________________ Partially adapted from: Clark E, Sweeney JK, Yocum A, McCoy SW. Effects of motor control intervention for children with idiopathic toe walking: a 5-case series. Pediatr Phys Ther. 2010;22(4):417-26. Child’s Name: _________________________ 2. Do any of these continue to toe walk? yes____ no_____ don’t know_____ If not, at what ages did they outgrow toe-walking?____________________________ Developmental History: If relevant, please indicate the age at which your child demonstrated the following skills: __rolling __standing alone __sitting __jumping __crawling __pull to stand Community Participation/Activities: If age appropriate, please respond to the following questions: 1. Does your child ride a bike alone? 2. Can your child swim alone? 3. What current sports, motor activity classes, or general physical activity does your child participate in? 4. What previous sports, motor activity classes, or general physical activity did your child participate in? More About Your Child Please answer all questions which feel applicable for your child’s age and concerns. 1. Does your child show any particular sensitivity to sound, lights, textures, or movement? If so, please describe. Partially adapted from: Clark E, Sweeney JK, Yocum A, McCoy SW. Effects of motor control intervention for children with idiopathic toe walking: a 5-case series. Pediatr Phys Ther. 2010;22(4):417-26. Child’s Name: _________________________ 2. Are there any particular activities and /or toys that your child enjoys, avoids, or dislikes? If so, please describe 3. How would you describe your child’s strengths? 4. Please circle all that apply to your child in the following questions: a. How would you describe your child when completing gross motor activities? Coordinated Clumsy Cautious Slower than peers decreased strength difficulty planning movement Easily frustrated gives up quickly eager Enjoys other b. How would you describe the activity level of your child? Very Active Active Not Active Average Less than average 5. Is there any additional information that you would like us to know about your child? Parent Signature:________________________________________________________________ Date: ___________________ Partially adapted from: Clark E, Sweeney JK, Yocum A, McCoy SW. Effects of motor control intervention for children with idiopathic toe walking: a 5-case series. Pediatr Phys Ther. 2010;22(4):417-26.
