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PEDIATRIC DEVELOPMENT & REHABILITATION PROGRAMCHILD HISTORY INTAKE FORM Child's Name: ___ LastFirstMiddleTodays Date: ___DOB: ___Name of person filling out this form: ___ Relationship to Child: ___
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How to fill out pt eval-child intake form
How to fill out pt eval-child intake form
01
Fill in the child's basic information such as name, age, date of birth, and contact information.
02
Provide details on the child's medical history, including any past injuries or surgeries.
03
Include information on the child's current symptoms or concerns that may necessitate physical therapy.
04
Note any medications that the child is currently taking.
05
Fill out any insurance information that may be required for billing purposes.
06
Sign and date the form to certify that the information provided is accurate.
Who needs pt eval-child intake form?
01
Children who are potentially in need of physical therapy services.
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What is pt eval-child intake form?
The pt eval-child intake form is a form used to gather information about a child's physical therapy evaluation.
Who is required to file pt eval-child intake form?
Parents or legal guardians of a child who is undergoing a physical therapy evaluation are required to file the pt eval-child intake form.
How to fill out pt eval-child intake form?
The pt eval-child intake form can be filled out by providing accurate information about the child's medical history, current physical condition, and reason for evaluation.
What is the purpose of pt eval-child intake form?
The purpose of the pt eval-child intake form is to collect essential information that will help the physical therapist determine the best course of treatment for the child.
What information must be reported on pt eval-child intake form?
Information such as the child's medical history, current physical condition, and any specific concerns or goals regarding the evaluation must be reported on the pt eval-child intake form.
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