Pediatric Medical Intake Form

Confidential Information

Parent(s)

Relationship

Add

Address

Country

State/Province

Health History

Birth History

Biological Child
Adopted
Foster Child

Delivery

Vaginal Forceps
C-Section
Vacuum Extraction

Postpardum complications?

Is your child currently under the care of a primary healthcare provider?

May I exchange information when necessary with this provider?

My child is developing:

like an average child for his/her age in all areas of development
differently than an average child his/her age in any area of development.

Please list medications, supplements or homeopathics the child is now taking - please include the following information listed below for each notation:

Medication/Herb/Etc:
Reason:
Started:
Dosage:

Please mark any of the following that your child now has or has had in the past. Identify the condition and location where applicable.

Skin Conditions

(includes rashes, topical allergies, fungal infections, etc.)

Now
Past

Muscle Conditions

(includes strains, tendonitis, spasms, cramps, etc.)

Now
Past

Joint Conditions

(includes sprain, arthritis, degenerating joints, etc.)

Now
Past

Nervous System Conditions

(includes numbness, tingling, nerve damage, shingles, etc.)

Now
Past

Infectious or Communicable Conditions

Now
Past

Respiratory Conditions

(includes sinus, lung and bronchial conditions, etc

Now
Past

Circulatory Conditions

(includes heart, blood pressure, arteries and venous conditions, etc.)

Now
Past

Reproductive Conditions

(includes pregnancy, prostate, menstruation, etc.)

Now
Past

Digestive Conditions

(includes constipation, diarrhea, ulcers, etc.)

Now
Past

Other Conditions

(includes any other health condition not previously listed)

Now
Past

Therapeutic History

Has you child ever received massage or another bodywork therapy

(professionally or by a parent’s touch)? (example: yoga therapy, cranial sacral therapy, bioaquatic therapy)

Please list other complementary therapies or educational programs in which your child participates:

May I exchange information when necessary with these providers?

Has your child been evaluated for or diagnosed with Sensory Integration Disorder?

Personal History

Please describe your child’s communication style:

Verbal
Word Approximations
ASL
PECs
Augmentative Device
Gestures None
Other

Does your child attend school/preschool/daycare?

I have listed all my child’s known medical conditions and physical limitations and will inform the massage therapist in writing of any changes between bodywork sessions. I understand that a massage therapist must be aware of any and all existing physical conditions that I have in order to provide appropriate massage. I further understand that a massage therapist neither diagnoses nor prescribes for illness, disease, or any other medical, physical, or emotional disorder, nor performs any thrusting joint or spinal manipulations or adjustments. I am responsible for consulting a qualified primary care provider for any physical ailment that my
the child may have.

I agree I will give twenty-four (24) hours notice to cancel any bodywork session to avoid being charged.

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	Never	Some/Often	Always	In the past	This is a problem
dislike being held or cuddled?
seem irritated when touched?
bang or hit head on purpose?
seem overly aware of touch, texture or temperature?
have an increased response to pain?
Lack awareness of being touched?
bite, chew or suck on blanket/pacifier/something to calm?
frequently bump into or push people or items?
have a strong need to touch objects and people?
try to bite people?
dislike being bounced, rocked or swung?
seek out rough-housing play?
have fear in space (i.e. on stairs, heights, etc.)?
dislike being off balance?

Pediatric Medical Intake Form

Thank you for your form submission!