Littlefield
Physical Therapy Caregiver Questionnaire
Child’s Name: __________________
Date of birth: ________________
Referring Diagnosis ________________________RX:___________________ Referring Physician:____________________________
Please complete appropriate information for your child’s situation.
Has your child ever had Yes/No
IF YES, what problems are present?
any issue in the
following areas?
Orthopedic
Yes/No
Neurological
Yes/No
Neurosurgical
Yes/No
Digestive
Yes/No
Ear/nose/throat
Yes/No
Feeding
Yes/No
Pulmonary/Breathing
Yes/No
Cardiac
Yes/No
Genetic
Yes/No
Visual
Yes/No
Hearing/Ear
Yes/No
Learning
Yes/No
Sleeping
Yes/No
Constipation
Yes/No
Dislikes touch
Yes/No
Physician Phone #:_____________________________
Doctor or clinic managing
condition
Next Follow up
visit or discharge
date
Medications
Littlefield
Physical Therapy Caregiver Questionnaire
Child’s Name: __________________
Date of birth: ________________
Dislike movement
Yes/No
Seizures
Yes/No
Surgeries
Yes/No
Other:
Yes/No
1. Precautions/Allergies:______________________________________________________________________________________
2. When did you begin to have concerns regarding your child’s development/condition?
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
3. What are your child’s strengths and preferences/likes?
______________________________________________________________________________________________________________________
4. Please list your current concerns:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
No If yes When___________________________________________
_____________
7. Has you child ever had or currently have any other thera
8. What would you like to accomplish with therapy for your child? _______________________________________________________________
______________________________________________________________________________________________________________________
_________________
Littlefield
Physical Therapy Caregiver Questionnaire
Child’s Name: __________________
Date of birth: ________________
DEVELOPMENAL HISTORY
1) Length of pregnancy: Gestational Age/Weeks ___________
2) Did you have any complications during your pregnancy? ‫ٱ‬seY ‫ٱ‬No
a.
Diabetes Excessive Vomiting Weight Loss Measles Bleeding
High Blood Pressure
Swelling
Other :________________________________________
3) Was the delivery Vaginal Cesarean Section
4) Did you have any problems during delivery? Yes NO
a. If yes please mark: Excessive blood loss
Premature rupture of membranes
breach birth
twisted cord
Other:________________________________________
Toxemia
5) Birth Weight:_____ Current weight_________ Any concerns regarding growth/weight gain: ____________________
6) Apgar Scores ____/10 @ 1 Minute, _____/10 @ 5 minutes
7) How long was your child hospitalized following delivery? __________________________________________
If yes explain:________________________________________________________________________
8) Please note the approximate ages at which your child accomplished the following milestones:
Rolled from stomach to back________________ months
Reached for objects____________________ months
Rolled from back to stomach
Crawled on stomach
__________________________ months
______________________ months
Crawled on hands and knees (Creeping) _____________________________ months
Sat independently with hands propping________________________ months
Sat independently without hands for support _______________________months
Stood independently ________________________ months
Walked independently_______________________ months
9)
eat,