Pediatric New Client Form Page 4
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7Neurologist Name: ______________________________________________________________________
Address: ______________________________________________________________________________
Telephone: ___________________________________
Orthopedic Evaluation:
Date & Results: _________________________________________________________________________
______________________________________________________________________________________
Orthopedist Name: __________________________________________________________________
Address: _______________________________________________________________________________
Telephone: _____________________________________________
Vision Test:
Date & Results: __________________________________________________________________________
_______________________________________________________________________________________
Ophthalmologist Name: ______________________________________________________________
Address: ________________________________________________________________________________
Telephone: ___________________________________
Optometrist Name: ___________________________________________________________________
Address: _________________________________________________________________________________
Telephone: _____________________________________
Hearing Test:
Date & Results: ____________________________________________________________________________
_________________________________________________________________________________________
Previous Therapy Interventions:
County-Based Early Intervention: PT
OT
ST
Other (explain): ______________________
________________________________________________________________________________________
School-Based: PT
OT ST
Other (explain): _____________________________________
_________________________________________________________________________________________
Private Therapy: PT
OT
ST
Other (explain): _________________________________
________________________________________________________________________________________
Other Physicians and Surgeons involved in child’s care with address & telephone:
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Parent category: Business