Physical Therapy Form Clinic Location Child has appointment scheduled at* Pooler Richmond Hill Name* Date of Birth* Month Day Year Today's Date* Month Day Year If your child is being evaluated for PT (physical therapy)... Please check any of the following performance skill areas that your child is having difficulty with.MOTOR SKILLS Tolerating Tummy Time Rolling Over Sitting Up Crawling Standing Walking Running Kicking Balance – Losing balance easily and/or uncoordinated Hopping on one foot Throwing Catching Jumping Pedaling tricycle or riding on bicycle Skipping Galloping SOCIAL SKILLS Following directions Making eye contact Participates in roughhouse play with others REGULATION Safety Awareness Impulsive/Risk taker Aggression towards self or others Has your child ever worn any type of braces, bars, and/or corrective shoes?* Yes No Additional Concerns: Δ