KidsCare Therapy Center: Registration Forms

The following questionnaire is to be completed by the patient's parent or legal guardian. This form has been designed to provide essential information before your initial appointment in order to make the most productive and efficient use of our time. Please feel free to add any additional information which you think may be helpful in understanding your child. KidsCare Therapy Center, Inc. will hold information provided by you as strictly confidential and will only be released in accordance with HIPPA guidelines and as mandated by law.

CHILD DEMOGRAPHICS:

Name of Child:

Gender

DOB

Age

Today's Date

Current Address

.FL

Parents and/or Guardians:

(Attach a copy of Driver License)

Best Number to Reach:

E-mail:

Emergency Contact Name (not living with you)

Relationship to child:

Current Diagnosis:

Referring Physician:

Current Address

.FL

Phone Number

EDUCATIONAL HISTORY

Name of School Center:

Principal/Contact Person:

Teacher’s Name:

Phone Number:

Fax Number:

E-mail:

Address:

MEDICAL HISTORY

1)- Please indicate at what age each major milestone was reached (N/A not applicable):

Rolled Over consistently:

Sat up unsupported:

Stood:

Crawled:

Walked Unassisted:

Said 1st Word Intelligible to strangers:

Said two-three word phrases:

Used Sentences regularly:

Toilet trained during the day:

Dressed Self:

Dry through the night (6+ months) :

2)- Was child premature?

3)- Born at how many weeks gestation?

4)- Was child premature?Did your child require any medical procedures before, during, or after birth? Please describe:

5)-Please check if your child has had any of the following disorders (and if so, at what age):

Seizures
Mumps
Diphtheria
Tonsillitis
Rheumatic fever
Respiratory disorders
Asthma

High fevers
Chicken pox
Head injury
Meningitis
Tuberculosis
Enlarged glands
Heart trouble

Measles
Whooping cough
Pneumonia
Encephalitis
Sinusitis
Thyroid
Diabetes

6)- Please indicate if your child is experiencing any of the following disorder:

Problems with eating
Isolated socially from peers
Problems making friends
Problems keeping friends
Problems getting to sleep
Problems controlling temper
Problems sleeping through the night

Fatigue/tiredness during the day
Trouble waking up
Nightmares
Bed wetting
Problems with authority
Anxiety
Unmotivated

Stress from conflict between parents
History of abuse
Alcohol/drug use/abuse
Sadness or Depression
School concentration difficulties
Grades dropping or consistently low

7)- List any operations, serious illnesses, injuries (especially head), hospitalizations, allergies, ear infections, or other special conditions your child has had.

8)- Child’s current:

Height:

Weight:

9)- With which hand does the child write?

10)- Does the individual have any vision problems?

11)- Does the child have any hearing problems?

12)- Please list any medical diagnosis present for the child:

Autism/PDD
Cerebral Palsy
Physical/Speech Delay
Learning Delay
Attention-Deficit/Hyperactivity Disorder
Vision/Hearing impairments
Other: