945 Sgt. Ed Holcomb Blvd
Conroe, Texas, 77304
Birgit Holback, RN, LMT
Sydney Knight, LMT
Chad Dickson, LMT
Emma Scott, RYT 200 Yoga
Pediatric Medical Information
Pediatric 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:
Improve pulmonary functions
Decrease symptoms of atopic dermatitis
Reduce colic / chronic abdominal pain
Promote growth for baby born prematurely/child
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
Promote orientation of extremities toward midline
Enhance child’s body awareness
Reduce chronic fatigue
Promote parent-child bonding
Other Goals: ______________________________________________________________________
Birth History: Biological Child Adopted Foster Child
Weeks gestation: _________ Delivery: Vaginal Forceps C-Section Vacuum Extraction
Postpartum 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.
Please list medications, supplements or homeopathics the child is now taking:
Please mark any of the following that your child now has or has had in the past. Identify the condition and location where applicable.
(includes rashes, topical allergies, fungal infections, etc.)
(includes sinus, lung and bronchial conditions, etc.)
(includes strains, tendonitis, spasms, cramps)
(includes heart, blood pressure, arteries and venous conditions, etc.)
(includes sprain, arthritis, degenerating joints)
(includes pregnancy, prostate, menstruation)
Nervous System Conditions
(includes numbness, tingling, nerve damage, shingles, etc.)
(includes constipation, diarrhea, ulcers)
Infectious or Communicable Conditions
(includes any other health condition not previously listed)
Other medical conditions, symptoms and/or further explanations: ____________________________
Please list any recent accidents, illnesses or surgeries (past 2 years -- or those that are still affecting your child): ________________________________________________________________________________
Please list any special dietary/nutritional considerations: (ie: gluten-free diet, allergies)
How do these symptoms affect the child’s daily life? _________________________________________________________________________________ Therapeutic History
Has you child ever received massage or another bodywork therapy (professionally or by a parent’s touch)? (example: yoga therapy, cranial sacral therapy, bioaquatic therapy) Yes No
If yes, please explain: _________________________________________________________________________________ _________________________________________________________________________________
Please list other complementary therapies or educational programs in which your child participates:
May I exchange information when necessary with these providers? Yes No
Has your child been evaluated for or diagnosed with Sensory Integration Disorder? Yes No
If yes, please explain evaluation, diagnosis and/or therapy program: _________________________________________________________________________________
In the past
This is a problem
dislike being held or cuddled?
seem irritated when touched?
bang or hit head on purpose?
seem overly aware of touch, texture or temperature?
have an increased response to pain?
Lack awareness of being touched?
bite, chew or suck on blanket/pacifier/something to calm?
frequently bump into or push people or items?
have a strong need to touch objects and people?
try to bite people?
dislike being bounced, rocked or swung?
seek out rough-housing play?
have fear in space (i.e. on stairs, heights, etc.)?
dislike being off balance?
How does your child respond to touch/movement? Does your child:
Please describe your child’s communication style:
Verbal Word Approximations ASL PECS Augmentative Device Gestures None
Other: ________________________________________________________________________________ How does your child deal with change? ________________________________________________________________________________ What types of methods does your child use to manage stressful situations (self-soothing techniques)?
_________________________________________________________________________________ ________________________________________________________________________________ What makes your child: (And, how do you deal with it)
Does your child attend school/preschool/daycare? Yes No
If yes, what are his/her teacher’s name(s)? _____________________________________________ What are the names/types of his/her pets? ______________________________________________
What are the names of his/her siblings? _________________________________________________ What are the names of his/her friends? _________________________________________________ What types of exercise interests your child? _____________________________________________ How does your child prefer to spend his/her time (hobbies/interests)? _________________________ _________________________________________________________________________________ I have listed all my child’s known medical conditions and physical limitations and will inform the massage therapist in writing of any changes between bodywork sessions. I understand that a massage therapist must be aware of any and all existing physical conditions that my child has in order to provide appropriate massage. I further understand that a massage therapist neither diagnoses nor prescribes for illness, disease, or any other medical, physical, or emotional disorder, nor performs any thrusting joint or spinal manipulations or adjustments. I am responsible for consulting a qualified primary care provider for any physical ailment that my child may have.
I agree I will give twenty-four (24) hours notice to cancel any bodywork session to avoid being charged.
Signed ________________________________________________ Date ____________________ Parent/Legal Guardian of ___________________________________________________________