Pediatric Client Intake Form (Page 3 of 4) in pdf

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: _______________________

Pediatric Client Intake Form Page 3

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