Child’s Name:                                                                                         

    Male:  Female:  Date of Birth:                            Age:                       

Parent/ Guardian Name(s):                                                                         

Address:                                                                                                   

Phone: Home: (     )                               Work: (     )                                   

    Cell: (     )                                          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:                Shoe Size                

4. Circumference of: Chest:               Waist:            Thigh:                

5. Medical Status:  Seizures (date of last one):                                                            

Scoliosis:                                                                                                                     

Heart Problems/ hypertension/ Past heart surgeries:                                                     

Lung Problems:                                                                                                           

Diabetes:                                                                                                                     

Vision/ Hearing:                                                                                                          

Shunts (hydrocephalus):                                                                                               

Tracheal/ G-Tube:                                                                                                       

Kidney Problems:                                                                                                        

Please provide names/phone numbers to ALL SPECIALISTS who treat your child:

6. Please list any MEDICATIONS your child is currently taking (dosage and reason for taking):  

7. Child’s ABILITIES (rolling, sitting, crawling, and walking):                                       

8. List of MEDICAL EQUIPMENT that your child is using (braces, walker, crutches, 

wheelchair, etc):                                                                                                          

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 therapy at a Europeds or Euromed Clinic?                                      

12. Please provide us with WRITTEN HIP X-RAY REPORT (no older than 6 months)

Please return completed form to the address/ fax# listed below.

1929 Main Street #103, Irvine, CA  92614

Phone: 949·797·9007 Fax: 949·797·9234