D.O.B |Fecha de Nacimiento:


Have any members or relatives had physical or serious health problems? (Ha tenido algún miembro de la familia problemas físicos, mentales o de salud serios?)
Did you take medication during your pregnacy, if so which? (Tomó medicamentos durante el embarazo, cuáles?)
Did you smoke or consume alcohol during your pregnancy? (Fumó o consumió alcohol durante el embarazo?)
Did you have any infections, illness, accidents or injuries during your pregnancy? (Tuvo usted alguna infección, enfermedad o golpes durante su embarazo?)
How Much Did your child weigh at birth? (Cuánto pesó su niño o niña al nacer?)
Was your delivery (Fue su parto)
How long was the delivery?(Cuánto tiempo duró su parto)
Did you receive medication during your delivery? (Recibió medicación durante su parto?)
Did your child have trouble breathing at birth? (Tuvo su niño o niña dificultad respiratoria alnacer?)
Did your child have any defects at birth? (Tuvo su niño o niña algún defecto al nacer?)
Did your child suffer from colic or other problems at birth? (Sufrio su niño o niña de cólicos u otros problemas al nacer?)
Sat without help (Se sentó sin ayuda)
In what lenguage (En que idioma)
Began to crawl (Empezó a gatear)
Began to combine words (Comenzó a combinar palabras)
Walked without help (Caminó sin ayuda)
Began to combine three or more words(Comenzó a combinar tres o mas palabras)

Which of the following illnesses does your child have:
(De las siguientes enfermedades cuáles tiene su niño/a:

Asthma-Asma Bronchitis-Bronquitis Convulsions-Convulsiones Dehydration-Desidratación
Epilepsy-Epilepsia High fever-Fiebre alta Tonsil Infection-Infección de anginas Throat Infection-Infección de garganta
Ear Infection-Infección de oido Meningitis-Meningitis Mumps-Paperas Bladder Problems-Problemas de vejiga
ear Infections-Infecciones de oido Kidney problems-Problemas de riñones Pneumonia-Neumonia Allergic reactions-Reacción alérgica
Frecuents Colds-Resfriados frecuentes Measels-Sarampión Chicken Pox-Viruela Other-Otros
Eating Problems
Problemas para comer
Behavior Problems
Problemas de conducta
Sleeping Problems
Problemas para dormir
Spoken Problems
Problemas de lenguaje
Vision Problems
Problemas de vision
Hearing Problems
Problemas para escuchar
Is your child taking medications, Which? (Está su niño/a tomando medicamento, cuál?)
Has your child suffered from blows to the head or other accident? (ha tenido su niño/a golpes en la cabeza o algún otro accidente?)
Has your child be hospitalized for any reasons? (ha tenido que ser hospitalizado su niño/a por alguna razón?)
In what situation does your child speak Spanish? (En Qué situación su niño/a habla español
In what situation does your child speak English? (En qué situación su niño/a habla inglés
What language does your child speak in school? (Qué idioma habla su niño/a en el colegio
How do you describe your child’s communication skills & what are you major concerns regarding this? (Cómo describiría la comunicación de su niño/a y cuáles son su mayores preocupaciones al respecto?
Do you have other information to add in regards to your child? (tiene alguna otra información adicional que considere importante sobre su niño/a?

Confidentiality Statement

It is the office policy of MD Therapy Solutions LLC, not to release confidential & or unauthorized information.
When returning telephone calls & a voice service picks up we will not leave a message if the name or telephone number is not on the record voice service to identify the residence. Information will also not be left with an unauthorized who may answer the telephone . If you require a healthcare information to be released to someone other than yourself, please complete the following:
I authorize MD Therapy Solutions LLC, to leave medical information pertaining to my care by the following methods and will assume responsability to notify them whenever this information changes.

May we reach you at home
May we confirm your appointments
by answering machine or text?
If you are employed, may we contact you at work?
It is important to keep your other physicians informed about your care. If needed, may MD Therapy Solutions LLC release medical records to your physicians?

Please list names of authorized people:

Parent (s)
Other (s) | Relationship

Patient Rights & Complaint Process

I understand that I have right to refuse treatment at any time. I have the right to review my records, diagnosis & tratment plan. I understand that if I feel that my rights have been violated, it is my right to file a complaint with the State of Florida.
I certify that I have read & understand the above & I accept all specified terms & fees therein & have received information on patient rights including the process for initiation, review & resolution of complaints.

HIPPA Compliance Notification for Our Patients

The misuse of protected health information has been indentified as a national problem causing some patient inconvenience, aggravation & costing them money. We want you to know that our staff periodically receives training to assist them in understanding & complying with government rules & regulations regarding the health insurance Portability & Accountability Act (HIPPA) with a particular emphasis on the “Privacy Rule”. We strive to achieve the highest standards of ethics & integrity in performing services for our patients.
When it is appropriate & necessary, we provide the minimum necessary information. Others entities may have indirect treatment relationships with you (such as physician reading your reports) & we may need to disclose personal health information for the purpose of treatment or payment. These entities are most often nor required to have patient consent.
You may refuse, in writing the consent to disclose your personal information. Under the law, we then have the right to refuse to treat you, should you refuse to disclose your personal health information. However you cannot revoke actions that have already been taken which relied on this or any previously signed consent.
It is our policy to determine appropriate uses of personal health information in accordance with the government rules, laws and regulations. We want to make sure that our office never contributes to the growing problem of improper disclosure of personal health information. We have implemented a program we believe will help us prevent inappropriate use of personal information.
We also know that we are not perfect, because of this fact our policy is to listen to our patients & employees without any thought of penalty if they feel that an event in any way compromises our policy or integrity . More so, we welcome your input regarding any service problem so that we may remedy the situation promptly . If you have any questions please ask to speak with any one of our staff concerning the problem.

Parents release form for Picture and / or Media Recording

I, the undersigned, do herby grant or deny permission to
MD Therapy Solutions LLC, to use the image of my child: , as marked by my selection below. Such use includes the display, distribution, publication, transmission or otherwise use of photographs, images, and/ or video taken of my child for use in materials that include, but may be limited to, printed materials such as brochures and newsletters, videos, and digital images such as those on a website.

Deny permission to use my child’s image at all.
Grant permission to use my child’s image in the following ways (mark all that apply)
Limited usage: I want my child’s image used within the MD Therapy Solutions LLC setting only (not in a larger community).
Limited usage: I want my child’s image for educational information only (not marketing). This could be either within MD Therapy Solutions LLC or in the larger community. One example of this could be videos in parent education classes.
Limited usage: I want my child’s image used on printed materials only (no digital or video use).
Unrestricted usage: I give unrestricted permission for my child’s image to be used in print, video, and digital media. I agree that these images may be used by MD Therapy Solutions LLC, for a variety of purposes and that these images may not be used without further notifying me. I do understand that the child’s last name will not be used in conjunction with any video or digital images

Dear Parents,

In unusual circumstances, it may be necessary for a therapist/ employee to physically restrain a patient in order to protect the patient and any other person form physical injury, or to protect property from serious damage if a child becomes aggressive.
Be aware that as the child’s parent (s) you are always in charge of termination of your child’s treatment.
As the parent of:
, I agree that MD Therapy Solutions LLC, and its employees shall not be liable for any damages and/or loss. I hereby verify by my signature below that I fully understand and accept the above conditions.

Dear Parents,

Food/Treats are often used as positive reinforcements for activity completion. We would like to guarantee that we are adhering to your child/ children’s diet or possible food allergies. Please fill out this form so that we may do so.

Child’s Name:
My child is allergic to:
My child is on the Gluten-Free Casein-Free (GFCF) diet
If so, it is okay to use wither popcorn or jellybeans that adhere to GFC guidelines
My child is not on the GFCF diet and their favorite reinforcements are
He/She is able to be given: (Please check appropriate boxes) Pretzels
Potato Chips Juices

Please feel free to bring in your own reinforcements from home.
Thank you for you cooperation.


The following form is a description of your good faith and veracity in all its details- Sending this form will be considered final before our consideration, therefore we recommend that you verify in detail that all the information is correct without omission in any line. Sending it is your acceptance of our terms and conditions. Thanks.