Physical Therapy (Out-Patient)

Paediatric Physical Therapy

Department: ___________________ Parents/Guardian Ph. No.________________________

Patient Name: ______________________________________ Age/Sex: ________________
Address: ___________________________________________________________________
Date of Birth: _________________________ Date of Diagnosis: ______________________
Diagnosis: ____________________ Source of Referral: __________________________

Medical History
Breastfeeding: Yes No
If Yes, Duration: _____________________
Onset of Breastfeeding: ___________________________________________________________
Sucking Condition: ______________________________________________________________
Birth Weight: ____ kg/lb
APGAR Score:
Appearance: ____________________________________________________________________
Pulse: __________________________________________________________________________
Grimace (Reflex/Irritability): ______________________________________________________
Activity: ________________________________________________________________________
Respiration: _____________________________________________________________________
Other Medical Conditions: _________________________________________________________
Previous Surgeries or Hospitalizations: ______________________________________________
Current Medications: _____________________________________________________________
Assessment
Motor Skills: ____________________________________________________________________
Balance and Coordination: ________________________________________________________
ROM: __________________________________________________________________________
Strength: _______________________________________________________________________
Endurance: _____________________________________________________________________
Pain Assessment: ________________________________________________________________
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 Special Tests Results Interpretation

Physical Examination: Mark on the body-chart deformities or joint anomalies:

Prenatal and Perinatal History:

Mother’s Prenatal Health: _________________________________________________________
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Mother’s Perinatal Health: ________________________________________________________
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Mode of Pregnancy: ______________________________________________________________
Duration of Delivery: _____________________________________________________________
Short Term Goals:
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Long Term Goals:

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Physical Therapy Treatment:

Modality: _______________________________________________________________________
________________________________________________________________________________
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ROM: __________________________________________________________________________
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Strengthening: ___________________________________________________________________
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Training (If Any): ________________________________________________________________
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Orthotic/Brace Recommendation: __________________________________________________
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Further Details: __________________________________________________________________
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