"Pediatric Client Intake Form"

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Pediatric Client Intake Form
Child’s Name _________________________________________ Birthdate ______________ Age ________
Parent(s) Name(s) ____________________________ Home Phone _______________________________
Work Phone ____________________________ Cell Phone _____________________________________
Street _______________________________ City_____________________ State _______ Zip _________
Parent Occupation/Employer _______________________________________________________________
Please mark your goals for your child’s Pediatric Massage Program:
Provide Comfort
Improve pulmonary functions
Promote relaxation
Decrease symptoms of atopic dermatitis
Reduce stress
Reduce lethargy
Reduce pain
Reduce colic / chronic abdominal pain
Ease Depression
Promote growth for baby born prematurely/child
Decrease anxiety
Improve self-soothing behavior
Reduce muscle hyper tonicity
Improve attentiveness and responsiveness
Improve muscle tone (decrease hypo tonicity)
Improve sleep patterns
Improve gastrointestinal functioning
Decrease hypersensitivity to touch
Improve joint mobility / range of motion
Encourage vocalization
Enhance child’s body awareness
Promote orientation of extremities toward midline
Reduce chronic fatigue
Promote parent-child bonding
Other Goals: _____________________________________________________________________________
Health History
Birth History:
Biological Child
Adopted
Foster Child
Weeks gestation: _________ Delivery:
Vaginal Forceps
C-Section
Vacuum Extraction
Postpardum complications?
No
Yes (describe): ___________________________________________
Is your child currently under the care of a primary healthcare provider?
Yes
No
Name of healthcare provider: ______________________________________________________________
Name of healthcare facility: ________________________________________________________________
Location: __________________________________________________ Phone: ______________________
May I exchange information when necessary with this provider?
Yes
No
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.
Describe: ______________________________________________________________________________
Page 1 of 4 Child’s Name: _______________________
Pediatric Client Intake Form
Child’s Name _________________________________________ Birthdate ______________ Age ________
Parent(s) Name(s) ____________________________ Home Phone _______________________________
Work Phone ____________________________ Cell Phone _____________________________________
Street _______________________________ City_____________________ State _______ Zip _________
Parent Occupation/Employer _______________________________________________________________
Please mark your goals for your child’s Pediatric Massage Program:
Provide Comfort
Improve pulmonary functions
Promote relaxation
Decrease symptoms of atopic dermatitis
Reduce stress
Reduce lethargy
Reduce pain
Reduce colic / chronic abdominal pain
Ease Depression
Promote growth for baby born prematurely/child
Decrease anxiety
Improve self-soothing behavior
Reduce muscle hyper tonicity
Improve attentiveness and responsiveness
Improve muscle tone (decrease hypo tonicity)
Improve sleep patterns
Improve gastrointestinal functioning
Decrease hypersensitivity to touch
Improve joint mobility / range of motion
Encourage vocalization
Enhance child’s body awareness
Promote orientation of extremities toward midline
Reduce chronic fatigue
Promote parent-child bonding
Other Goals: _____________________________________________________________________________
Health History
Birth History:
Biological Child
Adopted
Foster Child
Weeks gestation: _________ Delivery:
Vaginal Forceps
C-Section
Vacuum Extraction
Postpardum complications?
No
Yes (describe): ___________________________________________
Is your child currently under the care of a primary healthcare provider?
Yes
No
Name of healthcare provider: ______________________________________________________________
Name of healthcare facility: ________________________________________________________________
Location: __________________________________________________ Phone: ______________________
May I exchange information when necessary with this provider?
Yes
No
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.
Describe: ______________________________________________________________________________
Page 1 of 4 Child’s Name: _______________________
Please list medications, supplements or homeopathics the child is now taking:
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.
Now Past
Condition
Now
Past
Condition
Skin Conditions
Respiratory Conditions
(includes rashes, topical allergies,
(includes sinus, lung and bronchial
fungal infections, etc.)
conditions, etc.)
Type _________________________
Type _________________________
Location _______________________
Location _______________________
Muscle Conditions
Circulatory Conditions
(includes strains, tendonitis, spasms,
(includes heart, blood pressure,
cramps, etc.)
arteries and venous conditions, etc.)
Type _________________________
Type _________________________
Location _______________________
Location _______________________
Joint Conditions
Reproductive Conditions
(includes sprain, arthritis, degenerating
(includes pregnancy, prostate,
joints, etc.)
menstruation, etc.)
Type _________________________
Type _________________________
Location _______________________
Location _______________________
Nervous System Conditions
Digestive Conditions
(includes numbness, tingling, nerve
(includes constipation, diarrhea, ulcers,
damage, shingles, etc.)
etc.)
Type _________________________
Type _________________________
Location _______________________
Location _______________________
Infectious or Communicable
Other Conditions
Conditions
(includes any other health condition not
previously listed)
Type _________________________
Type _________________________
Location _______________________
Location _______________________
Other medical conditions, symptoms and/or further explanations: ____________________________________
________________________________________________________________________________________
Page 2 of 4 Child’s Name: _______________________
Please list any recent accidents, illnesses or surgeries (past 2 years -- or those that are still affecting your
child): ________________________________________________________________________________
_____________________________________________________________________________________
Please list any special dietary/nutritional considerations: (ie: gluten-free diet, allergies) _________________
______________________________________________________________________________________
How do these symptoms affect the child’s daily life? ____________________________________________
______________________________________________________________________________________
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)  Yes  No
If yes, please explain: ___________________________________________________________________
______________________________________________________________________________________
Please list other complementary therapies or educational programs in which your child participates:
Therapy/Program
Reason
Started
Practitioner
 Yes  No
May I exchange information when necessary with these providers?
 Yes  No
Has your child been evaluated for or diagnosed with Sensory Integration Disorder?
If yes, please explain evaluation, diagnosis and/or therapy program: _________________________________
_______________________________________________________________________________________
How does your child respond to touch/movement? Does your child:
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?
Page 3 of 4 Child’s Name: _______________________
Personal History
Please describe your child’s communication style:
 Verbal
 Word Approximations
 ASL
 PECs
 Augmentative Device
 Gestures None
Other: __________________________________________________________________________________
How does your child deal with change? _______________________________________________________
_______________________________________________________________________________________
What types of methods does your child use to manage stressful situations (self-soothing techniques)?
_______________________________________________________________________________________
_______________________________________________________________________________________
What makes your child:
(And, how do you deal with it)
Happy?
Sad?
Angry?
Stressed?
Excited?
 Yes  No
Does your child attend school/preschool/daycare?
If yes, what are his/her teacher’s name(s)? ____________________________________________________
What are the names/types of his/her pets? ____________________________________________________
What are the names of his/her siblings? _______________________________________________________
What are the names of his/her friends? ________________________________________________________
What types of exercise interests your child? ___________________________________________________
How does your child prefer to spend his/her time (hobbies/interests)? ________________________________
________________________________________________________________________________________
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
child may have.
I agree I will give twenty-four (24) hours notice to cancel any bodywork session to avoid being charged.
Signed ________________________________________________ Date ____________________
Parent/Legal Guardian of ___________________________________________________________
Page 4 of 4 Child’s Name: _______________________
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