TheraKids Plus, Inc. Physical Therapy Questionnaire Physical therapy Questionnaire - English Patient Name(Required) First Last Telephone Contact(Required) Date of Birth(Required) MM slash DD slash YYYY MOTOR DEVELOPMENT / EQUIPMENTPlease check all that your child is displaying or using: Activity Poor muscle tone Poor body control Torticollis Contractures Trouble walking independently Wears orthotics Wears leg braces Uses a wheelchair Uses a feeder seat Uses a walker / cane Describe: SKILL DEVELOPMENTPlease check all that apply to your child:Holds Head up Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Rolls over Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Sits up unassisted Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Crawls independently ARMY HANDS & KNEES Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Brings hands together at midline Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Pulls to sit or stand up Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Accepts weight into legs Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Stands holding onto furniture Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Stands independently Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Walks holding onto hand / furniture Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Walks independently Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Runs Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Throws a ball Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Catches a ball Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Jumps with two feet Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Hops Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Skips Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Balances on one foot Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Kicks a ball Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Grasps objects Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Transfers objects from hand to hand Independent (90-100% of time) Emerging (50% of time) Not Yet Achieved Does your child wear glasses? Yes No Does your child have fall precautions ? Yes No Does your child have seizures? Yes No
