CHILD'S  NAME:
SEX:	MALE FEMALE
DATE OF BIRTH:
PARENT / GUARDIAN NAME:
ADDRESS:
PHONE: HOME
FAX:
E- mail:
1. WHAT IS THE CHILD’S DIAGNOSIS:
2. GIVE  MEDICAL / SURGICAL HISTORY:
- HISTORY OF BOTOX/PHENOL INJECTIONS
- HISTORY OF INHIBITIVE / SERIAL CASTING  (DATES)
- HISTORY OF FRACTURES
3. WHAT IS THE CHILD'S:
- HEIGHT
- WEIGHT
4. CIRCUMFERENCES OF:
CHEST
WAIST
THIGH
5. MEDICAL STATUS
- SEIZURES (date of last one)
- SCOLIOSIS
- HEART PROBLEMS / HYPERTENSION / PAST HEART SURGERIES
- LUNGS PROBLEMS
- DIABETES
- VISION/HEARING
- SHUNTS (hydrocephalus)
- TRACHEAL/G- TUBE
- KIDNEY PROBLEMS
6. PLEASE LIST ANY MEDICATIONS YOUR CHILD IS CURRENTLY TAKING (and reason for taking)
7. CHILD ABILITIES (rolling, sitting, crawling, and walking):
8. LIST OF MEDICAL EQUIPMENT THAT YOUR CHILD IS USING:     (braces, walker, crutches, wheelchair)
9. HOW DO YOU COMMUNICATE WITH YOUR CHILD / HOW DO THEY COMMUNICATE WITH YOU ?
10. IS YOUR CHILD ABLE TO FOLLOW SIMPLE COMMANDS:
11. HAVE YOU EVER BEEN  DENIED SUIT THERAPY?        ( IF YES PLEASE EXPLAIN WHERE, WHEN AND WHY )
12. PLEASE PROVIDE US WITH  WRITTEN HIP X-RAY REPORT  (NO OLDER THAN 6 MONTHS)