APTA members may download and adapt this form only for …



Annual Physical Therapy Visit Template: PediatricAPTA members may download and adapt this form only for use in their practice with individual clients. For all other uses, permission or licensing must be obtained from APTA, permissions@.This form provides standardized elements and suggested tests and measures for those elements to be included in an annual checkup for the Pediatric population (e.g., children with developmental disabilities who have been discharged from routine care). The form also provides links to APTA’s Tests & Measures webpage to help you select alternative tests for individuals who have chronic disease or disability.The standardized Annual Checkup is designed to take approximately 30 to 60 minutes depending on the client and the presence of chronic disease or disability. It is recommended that, at a minimum, the physical therapist collect and document the data obtained through the use of tests and measures for all elements in each category in the left column. Additional testing can be performed at therapist’s discretion.KeyBe sure to include the population you are addressing at the top of the right column.Include notes in the right column with questions, observations, screens, and tests and measures appropriate to the identified population.Provide references and psychometrics if known.Annual Physical Therapy Visit: Pediatric Population TemplateName of Therapist Completing this Form: Click here to enter.Name of Child: Click here to enter.Personal Health ProfileDemographicsCollect individual’s demographic information.Date of Birth: Click here to enter.Sex: ? Female? MaleChild’s primary caregiver(s): Click here to enter.Ethnicity:? Hispanic or Latino? Not Hispanic or LatinoRace:? American Indian or Alaska Native? Asian? Black or African American? Native Hawaiian or Other Pacific Islander? White or Caucasian? Unknown/Decline to answerIs the child currently in early intervention/pre-school/childcare program:? Yes? NoIf yes, please indicate current school or service provider: Click here to enter.Current grade level (e.g., pre-K, K, 1, 2, 3): Click here to enter.Enough food to eat:? Yes? NoAdequate housing:? Yes? NoAccess to health care:? Insured? Underinsured? UninsuredMedical, Surgical, and Family History:Collect information specifically regarding individual’s medical and surgical history.Does the child have a primary care provider or agency?? Yes? NoIf yes, name provider or agency: Click here to enter.If no, name any previous provider or agency: Click here to enter.Does the child see any other health care specialists (orthopedic, neurologic, other)?? Yes? NoDoes the child have a primary diagnosis? ? Yes? NoIf yes, please describe: Click here to enter.Are there any issues that affect the child’s health/function/movement?? Yes? NoIf yes, please describe: Click here to enter.Does the child have any precautions/contraindications to movement/positioning?? Yes? NoIf yes, please describe: Click here to enter.Does the child take any medications?? Yes? NoIf yes, please list (include dosage if known): Click here to enter.Medical and Surgical History, Including Current Prescription Medications:Collect information specifically regarding individual’s medical history within the past year.Condition (check all that apply):Relationship to child:Age of onset (if known):?Blood disorderClick here to enter.Click here to enter.?Circulation/vascular problemsClick here to enter.Click here to enter.?Heart problemsClick here to enter.Click here to enter.?High blood pressureClick here to enter.Click here to enter.?Lung problemsClick here to enter.Click here to enter.?StrokeClick here to enter.Click here to enter.?Diabetes/high blood sugarClick here to enter.Click here to enter.?Low blood sugar/hypoglycemiaClick here to enter.Click here to enter.Condition (check all that apply):Relationship to child:Age of onset (if known):?Muscular dystrophyClick here to enter.Click here to enter.?Seizures/epilepsyClick here to enter.Click here to enter.?AllergiesClick here to enter.Click here to enter.?Developmental or growth problemsClick here to enter.Click here to enter.?Thyroid problemsClick here to enter.Click here to enter.?Thyroid problemsClick here to enter.Click here to enter.?CancerClick here to enter.Click here to enter.?Infectious disease (e.g., tuberculosis, hepatitis)Click here to enter.Click here to enter.?Kidney problemsClick here to enter.Click here to enter.?Repeated infectionsClick here to enter.Click here to enter.?Ulcers/stomach problemsClick here to enter.Click here to enter.?Skin diseasesClick here to enter.Click here to enter.?Depression/anxiety/other mental health concernsClick here to enter.Click here to enter.?SeizuresClick here to enter.Click here to enter.?Difficulty with muscle tone or unusual movementsClick here to enter.Click here to enter.?Other: Click here to enter.Click here to enter.Click here to enter.Collect information specifically regarding child’s medical history within the past year:?Bowel problems (e.g., constipation, leakage of gas or stool, irritable bowel syndrome)?Coordination problems?Difficulty with muscle tone or unusual movements?Seizures?Dental caries?Difficulty sleeping?Difficulty swallowing?Difficulty walking?Difficulty with weakness or muscle fatigue?Dizziness or blackouts?Headaches?Hearing problems?Heart palpitations?Joint pain or swelling?Loss of appetite?Loss of balance?Pain at night?Problems with sensation?Repeated fever, chills, or sweats?Shortness of breath?Unexplained nausea/vomiting?Unexplained weight loss/gain?Urinary problems?Vision problems?Other problems: Click here to enter.Has the child ever had surgery/hospitalization?? Yes? NoIf yes, please describe, and include dates: Event: Click here to enter.Month: Click here.Year: Click here.Personal Factors:Collect information regarding child’s preferred communication and learning style, preferred language, confidence or self-efficacy level, social support, exposure to abuse or neglect, and environmental factors that impact personal health.What is the child/family’s preferred language? Click or tap here to enter text.What is the child’s primary means of communication? Click or tap here to enter text.Is a sign language or language interpreter needed for this visit?? Yes? NoWhat is the support/caregiver’s preferred communication method? Click or tap here to enter text.Environmental Factors:Is there any emotional, physical, or mental abuse/neglect in the home or school? ? Yes? NoIf yes, please describe: Click here to enter.Are there any barriers in the home setting, such as stairs, that limit ? Yes? Nothe child’s ability to independently move throughout the home?If yes, please describe: Click here to enter.Are there any barriers in the school setting that limit the child’s ability ? Yes? Noto independently move throughout the school?If yes, please describe: Click here to enter.Does the child use any adaptive equipment (wheelchair, walker, special seating, ? Yes? Nofeeding devices, toileting, respiratory, other)?If yes, please list: Click here to enter.Does the child use any assistive technology (hearing aid, glasses, ? Yes? Nocommunication device, other)?If yes, please list: Click here to enter.Disease Risk ProfileChild and Family Goals and Aspirations/Quality of LifeWhat activities does the child enjoy and do best?Click here to enter.What are the child’s/family’s strengths?Click here to enter.What dreams do the child/family have for the future?Click here to enter.What fears/concerns does the parent(s)/caregiver(s) have?Click here to enter.Current Health Profile and BehaviorsCollect information on individual’s exercise or physical activity, nutrition, and sleep.Physical activity:How much time per day does the child spend engaged in physical activity?? <30 minutes? 30 minutes–1 hour? 1–2 hours? 2–3 hours? >3 hoursHow much screen time does the child watch per day (TV, computer, tablet, videogames, etc.)?? <30 minutes? 30 minutes–1 hour? 1–2 hours? 2–3 hours? >3 hoursPlease describe what limits the child’s ability to engage in desired level of physical activity:Click here to enter.Current Health Profile and BehaviorsNutrition:Does the child get adequate fluid? ? Yes? NoDoes the child eat a well-balanced diet?? Yes? NoNumber of glasses of sugary drinks/juice on an average per day:? 0? 1? 2? 3? 4? >4Is the child on a special diet? ? Yes? NoIf yes, please list the diet: Sleep:How many hours of sleep does the child get on average per night? Click here to enter.Hearing, VisionEstimate individual’s hearing and visual acuity:Does the child have difficulty hearing?? Yes? NoIf yes, does the child wear hearing aids or cochlear implants? ? Yes? NoDoes the child have difficulty seeing?” ? Yes? NoIf yes, does the child wear glasses or contact lenses? ? Yes? NoTests: CALFRAST and Snellen chart**Reliability has not been established for children, but test has been used successfully for children aged 3–4.ImmunizationsAre the child’s immunizations up to date?? Yes? NoStandard Physical ExaminationVital SignsHR: Click here to enter.RR: Click here to enter.BP: Click here to enter.SaO2: Click here to enter.Body CompositionHeight: Click here to enter.Weight: Click here to enter.BMI: Click here to enter.Waist circumference: Click here to enter.Mental FunctionsAre there concerns regarding cognitive function or mental health? ? Yes? NoClick here to enter.Integumentary StatusAre there any visible bruises, scrapes, abrasions, or blisters of the child’s skin? ? Yes? NoClick here to enter.Any signs of skin breakdown? ? Yes? NoClick here to enter.PainCollect data on pain using a standardized tool.Does the child have pain?? Yes? NoIf yes, what makes it occur? What makes the pain feel better? Click here to enter.Numeric Pain Rating Scale / Visual Analog Pain Scale orFACES Pain Scale orFaces, Legs, Activity, Cry, Consolability (FLACC) Behavioral Pain ScalePhysical Performance ExaminationMobility Functional transfers (sit to stand, supine to sit)Developmental motor skills such as: (standardized tests)Peabody Developmental Motor Scales, Second Edition (PDMS-2) Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOTS-2)Click here to enter.Quality of MovementMuscle tone:? Normal? AbnormalDescribe: Click or tap here to enter text.Other description of movement or movement pattern: Click here to enter.PostureObservationLying:Prone Click here to enter.Supine Click here to enter.Sidelying Click here to enter.Rolling Click here to enter.Sitting:Chair/wheelchair/edge of mat or bed Click here to enter.Sit to/from stand Click here to enter.Sit and reach Click here to enter.Standing:Stable/unstable surface Click here to enter.Stand and reach (distance and qualitative measures) Click here to enter.StrengthFunctional Strength Assessment:Movement (indicate anti-gravity, gravity-lessened, active-assisted, other where appropriate)Gross motor (e.g., rolling, sit to/from stand, creeping, walking, throwing) Click here to enter.Fine motor (e.g., grasping, writing, manipulation of a toy) Click here to enter.Manual muscle testing (trunk, upper and lower extremities) Click here to enter.Dynamometer Click here to enter.Lower extremity objective strength measurements (e.g., Kinex/Biodex) Click here to enter.Range of MotionJoints/region (indicate position in which measurement taken)Click here to enter.Flexibility/Functional Range of MotionExamples:90/90 passive popliteal/hamstring flexibility Click here to enter.Straight leg raise Click here to enter.Hooklying pectoralis minor Click here to enter.Other Click here to enter.Aerobic CapacityExamples: 6-Minute Walk Test1-Minute Walk Test1-Minute Push TestClick here to enter.Locomotion SpeedGait speed (distance/ time): Click here to enter.Manual wheeled mobility speed (distance/time):Click here to enter.BalanceExamples: Single-leg stance test (eyes open/closed)Pediatric Balance ScaleEarly Clinical Assessment of Balance (ECAB)Click here to enter.SensationComplete based on response to light touch/observation.Click here to enter.Other Individualized Tests as NecessaryCategoryDescription or name for information collectedClick here to enter.Click here to enter.Click here to enter.Click here to enter.Click here to enter.Click here to enter.Last Updated: 08/03/2020Contact: practice@ ................
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