Bright Steps Forward

Untitled Document

Client Information Form

IMPORTANT: After completing registration, please send us, via email, three or more digital pictures of your child and her/his story to be featured in the "Sponsor a Child" section of our website. Look in the "Sponsor a Child" pages to see other children's web pages. See Instructions.

Date:
Patient Information
Name (First, Last):
Date of Birth:
Age:	Male Female
Guardian (First, Last):
Address:
City / State / Zip:
Home Phone:	Work Phone:
Mobile Phone:	Fax:
Email Address:
Referring Physician
Name (First, Last):
Phone:	Fax:
Address:
City / State / Zip:
Is this your regular doctor? Yes No
If no, list your Regular Doctor
Name (First, Last):
Phone:	Fax:
Address:
City / State / Zip:
Medical Information
Date of Onset of Illness:
If accident, how, where, and when did it happen?

Primary Diagnosis:
Secondary Diagnosis:
Precautions (swallowing, apnea, seizures, blood pressure, diabetes, etc.):

Weight:	lbs. Height: feet inches
Shoe Size w/o Braces:	Show Size with Braces
Medical Equipment (Oxygen, Trach Tube, Suction Pump, etc.):

Current Medications:

Allergies (Foods, Textures, etc.):

Please indicate if your child has a history of any of the following surgeries:
Fractures:	Yes
Date:
Notes:
Castings:	Yes
Date:
Notes:
Muscle/Tendon Lengthening/Release:	Yes
Date:
Notes:
Eye Repair:	Yes
Date:
Notes:
Subluxation:	Yes
Date:
Notes:
Dorsal Selective Rhizotomy:	Yes
Date:
Notes:
Baclofen Pump:	Yes
Date:
Notes:
Osteotomy:	Yes
Date:
Notes:
Spinal fusion/rods:	Yes
Date:
Notes:
Scoliosis:	Yes
Date:
Notes:
V-P Shunt (hydrocephalus):	Yes
Date:
Notes:
Gastrointestinal Tube:	Yes
Date:
Notes:
Botox/Phenol Injections:	Yes
Date:
Notes:
Tracheotomy Tube:	Yes
Date:
Notes:
Any Other Surgeries:	Yes
Date:
Notes:
Date of Last Hip X-Ray:
Date of Last Spine X-Ray:
Child's Primary Caregiver:
Last Complete Check-Up:
Has the Child Ever Had a Check-Up at the Health Department? Yes No
Where:
Has the Child Been to the Dentist? Yes No
When:
Where:
Has the Child Been in the Hospital Recently? Yes No
Does the Child Suffer from Seizures? Yes No
Are there any concerns regarding the Child's Health? Yes No
If any, what are they?

Please indicate if your child has contracted the following diseases:
Chicken Pox German Measles Measles Whooping Cough
Pneumonia Frequest Chest Infections Mumps Others
Had this Child Ever Had a Vision or Hearing Screening? Yes No
Brief Past Medical History About Child's Birth, Development and Illness
Did the mother go to a doctor during pregnancy? Yes No
Was the pregnancy:	Complicated Uncomplicated
Baby Problems at Birth?	Yes No
If yes, which:	Convulsions Trouble Breathing Jaundice
	Injury Other
Was the Child Premature?	Yes No
Gestational Age:
Length of mothers labor:
Delivery was:
Birth Weight:	lbs ozs. Length: inches
Any Complications?
Did the mother use drugs or alcohol during pregnancy? Yes No
Explain:
Developmental Milestones:
Please check all milestones the child has achieved and approximate age when achieved:
Head Control:	Yes Age:
Rolled:	Yes Age:
Sat:	Yes Age:
Crawled:	Yes Age:
Walked:	Yes Age:
How much assistance, if any, does your child need with:
Feeding
Hygiene/Grooming
Bathing
Dressing
Toileting
General Information:
How do you & your child talk to each other?
Examples: nodding head, talking, communication device, sign language, other)
Simple commands your child can understand:

Current Skills (rolling, reaching, crawling, sitting, etc):

Does your child exhibit any aggressive behaviors?
Examples: biting, hair pulling, etc.
Adaptive Equipment (Walker, Wheelchair, Stroller, AFO's, Handsplints, etc)

Things Your Child Enjoys:

Child Attend School?	Yes No
Child Receiving Therapy?	Yes No
Check all that apply:	ST OT PT
When Are You Interested in Attending the Program?
Will you be participating in the Hyperbaric Oxygen Therapy? Yes No
Parents goal for the child at completion of the Intensive Pediatric Therapy using TheraSuit:

I Would Like To:	Get a Phone Call
	Talk to the Doctor
	Receive More Information
	Type the text from the image:
I Agree	By submitting this form with your telephone number you are consenting for Bright Steps Forward and all authorized representatives to contact you even if your name is on a Federal or State Do-not-call list. Please check to submit.