MIF FILL

CHILD'S NAME:
SEX:
DATE OF BIRTH:
PARENT / GUARDIAN NAME:
ADDRESS:
PHONE: HOME
FAX:
E- mail:


1. WHAT IS THE CHILD’S DIAGNOSIS:


2. GIVE MEDICAL / SURGICAL HISTORY:
- HISTORY OF BOTOX/PHENOL INJECTIONS
- HISTORY OF INHIBITIVE / SERIAL CASTING (DATES)
- HISTORY OF FRACTURES


3. WHAT IS THE CHILD'S:
- HEIGHT
- WEIGHT


4. CIRCUMFERENCES OF:
CHEST
WAIST
THIGH


5. MEDICAL STATUS
- SEIZURES (date of last one)
- SCOLIOSIS
- HEART PROBLEMS / HYPERTENSION / PAST HEART SURGERIES
- LUNGS PROBLEMS
- DIABETES
- VISION/HEARING
- SHUNTS (hydrocephalus)
- TRACHEAL/G- TUBE
- KIDNEY PROBLEMS

6. PLEASE LIST ANY MEDICATIONS YOUR CHILD IS CURRENTLY TAKING (and reason for taking)

7. CHILD ABILITIES (rolling, sitting, crawling, and walking):

8. LIST OF MEDICAL EQUIPMENT THAT YOUR CHILD IS USING: (braces, walker, crutches, wheelchair)

9. HOW DO YOU COMMUNICATE WITH YOUR CHILD / HOW DO THEY COMMUNICATE WITH YOU ?

10. IS YOUR CHILD ABLE TO FOLLOW SIMPLE COMMANDS:

11. HAVE YOU EVER BEEN DENIED SUIT THERAPY? ( IF YES PLEASE EXPLAIN WHERE, WHEN AND WHY )

12. PLEASE PROVIDE US WITH WRITTEN HIP X-RAY REPORT (NO OLDER THAN 6 MONTHS)


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