Pediatric Physical Therapy, LLC

Wiggle Worms

Pediatric Physical Therapy, LLC

Pediatric Case History

Patient: ______Today’s Date: ______

DOB: ______

Statement of the problem:______

When it was first noticed? ______

What was done about it?______

Primary Care Physician:______

Social History:

Child lives with: Mother Father Both

Mother’s Name:______

Father’s Name: ______

# of Siblings:______

Siblings Age(s):______

Any family medical concerns? History of physical, emotional, speech, hearing, or learning problems in the family? Please describe: ______

______

Emergency Information:

Person to contact if parents can’t be reached:______

Phone: ______

If we are unable to reach you, do we have your permission to take your child to a hospital if necessary? Yes No

In the event that I (the parent) can’t be reached, I give my permission for a member of Wiggle Worms PT to obtain any treatment deemed necessary by a physician.

Signed: ______

Previous Examinations and Treatments

Examination / When / Where / By Whom
Speech Evaluation
Speech Therapy
Neurological
Psychological
Occupational Therapy Evaluation
Occupational Therapy
Physical Therapy Evaluation
Physical Therapy

Does your child’s physician have any concerns about his/ her growth and development? ______

Pregnancy and Birth History

Mother’s age when child was born: ______

Length of Pregnancy: ______

Did you have any problems with your health during pregnancy? Please Describe: ______

___ Edema___ Unusual Bleeding ___ Physical Trauma

___ Gestational Diabetes___ RH Incompatibility ___ Toxemia

___ Nausea and Vomiting___ Fainting Spells

Did the mother use any medications/ substances during pregnancy?

___ birth control pills ___ antibiotics___ sleeping pills

___ cigarettes___ alcohol___ Other:

______

Birth Weight of Child: ______Apgar Scores: ______

How long was your labor: ______Were you induced: YN

Were there any complications experienced during delivery?

Instruments used ______

Bruises or abnormalities ______

Premature birth ______

Breech Presentation ______

Unusually long labor ______

Anoxia ______

Cesarean ______

Multiple births ______

Conditions Immediately Following Birth

Was the child incubated?YNHow Long? ______

Did the infant have trouble starting to breath? YN

Was the infant blue? YN

Was the infant given Oxygen? Y N

Was the infant floppy? Y N

Was the infant jaundiced? YN

Did the infant have feeding difficulties? YN

Were their any seizures? YN

Medical History___

___ Ear Infections___ Bronchitis ___ Whooping Cough

___ Earaches___ Scarlet Fever___ Frequent Colds

___ Measles___ Head Injury___ Chicken Pox

___ Asthma___ Pneumonia___ Croup

___ Influenza___ High Fevers___ Sinus Infections

___ Tonsillitis___ Meningitis___ Rheumatic Fever

___ Other ____Allergies:______

Was the child ever hospitalized?______

Dates? ______

Why? ______

Where? ______

Current Medications: ______

Motor Milestones: At what age did the following occur?

______held head up on own______sat alone

______rolled over from back to belly (both ways?) YN

______belly crawl______Crawling on hands and knees

______Pull to stand______Standing alone

______walking alone

Parent Signature: ______

Wiggle Worms Pediatric Physical Therapy, LLC

764 US Route 1 Unit 4

York, ME 03909

Wiggle Worms Pediatric Physical Therapy

Patient:DOB:

Medical Record Number:

I consent to procedures, treatments or planned recurring treatments that the Occupational Therapist deems necessary.

I understand that I have the right to be informed about the risks, benefits, and alternatives to any care, treatment or procedure before I receive it.

I have the right to accept or refuse any medical care, treatment or procedure.

I give permission for the Therapist to take photo’s of my child as needed during the course of treatment.

I authorize the release of medical information needed to continue my care or to determine benefits for the services rendered.

I request that all payment of authorized benefits be made directly to Wiggle Worms Pediatric Physical Therapy and all therapists involved in my care.

I am aware that the Wiggle Worms Pediatric Physical Therapy privacy notice booklet has further information about how medical information may be used and disclosed. I have had the opportunity to receive and review this booklet and may request an updated copy at any time.

______

Signature of Patient or Legal Guardian Date

______

Signature of Witness Date

Wiggle Worms

Pediatric Physical Therapy, LLC

764 US Route 1 Unit 4 York, ME03909

Ph: 207- 351- 3078, Fax: 207- 351- 3083

Patient Agreement Form

Patient Name:______

Patient DOB:______

Parent/ Guardian Names:______

Insurance

I am responsible for any deductibles, co- pay’s, or co- insurance payments associated with my insurance benefit. I understand that I am responsible for payments not covered by my insurance plan. I understand that my insurance company will be sent an itemized bill for therapy sessions in accordance to reasonable and customary charges. I understand that I must notify Wiggle Worms Pediatric PT of any insurance changes immediately. ______(Initial) (Mainecare) (CDS)

HIPPA

I acknowledge that I have received and understand the HIPPA privacy standards. ______(Initial)

Cancellation Policy

Successful physical therapy takes a strong commitment on both the side of the therapist as well as the family. Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. We reserve the right to charge a fee for canceled or missed appointments. For cancellations, a 24 hour notice prior to your appointment is requested otherwise it is considered a missed appointment. A $25 fee will be charged for a second and any additional missed appointments without appropriate notice.______(Initial)

In the event the patient will be more than 5 minutes late for a therapy session, a phone call to Wiggle Worms will be required. Treating therapists will be required to stay at the clinic for 15 minutes in the event a patient is late and has not called. After 15 minutes without a phone call, the patient will be considered a no- show and the therapist will not be required to stay in the clinic.______(Initial)

After a third missed appointment within a 2 month period a meeting will need to take place to discuss your child’s progress and the possibility of a different schedule to meet your needs and your child’s therapy goals. ______(Initial)

______

Parent Signature Date