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Information Packet
Medical Clearance

Patient Information Form

* Patient Name:
* Date of Birth:
* Patient Height:
* Patient Weight:
* Patient Shoe Size without AFOs:
with AFOs:
* Address:
* Phone Number: () -
* Mother’s Name:
* Cell / Work Number: () -
Mother's email::
Father’s Name:
Cell / Work Number: () -
Father's email:
* Patient Diagnosis:
* Referring Physician:
* Referring Physician Contact Number: () -
List of Medications patient is taking:
Born at how many weeks gestation?:
* Any complications with pregnancy?:
If yes, please explain:
Please list any previous surgeries and dates:
* Does your child have seizures?:
Date of last seizure:
Are seizures controlled with medications?:
How frequently do seizures occur?:
* Does your child have a shunt?:
* Does your child have any cardiac conditions?:
If yes, please describe:
* Does your child have high blood pressure?:
* Does your child have a G-tube?:
* Has your child ever had a hip dislocation , subluxation, or fracture:
If so, which hip and degree of subluxation:
Date of occurrence:
Was it repaired?:
* Does your child have a bone condition or brittle bone disease:
* Does your child have scoliosis?:
Type & Degree of curvature:
* Does your child have respiratory conditions?:
* Does your child have diabetes:
* Does your child have any behavioral or social concerns?:
* Please list any other conditions not mentioned above in which precautions need to be taken or in which intensive suit therapy might be contraindicated:
  (Please list even if you are not sure)
Please indicate what developmental milestones your child has achieved. Check all that apply::
* Please list what areas you would like to be addressed in therapy:
* Please list your goals for your child:
Additional Comments / Concerns: