Pediatric Client Intake Form
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4Pediatric 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: _______________________
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