4 Years and Up Physical Therapy Questionnaire Child's Name * Child's Age * Parent's Name * Parent's Email * Can your child walk alone and run (ie. without assistance or hand holding, maintaining balance, does not walk on toes, minimal side-to-side movement)? ---YesSometimesNo Can your child walk up and down stairs (ie. does not crawl or scoot, does not move sideways with railing, does not trip or fall)? ---YesSometimesNo Can your child pedal a tricycle? ---YesSometimesNo Can your child jump in place (ie. feet clear the floor)? ---YesSometimesNo Can your child stand on one foot for 5 seconds? ---YesSometimesNo Can your child kick a ball without holding onto an object for support? ---YesSometimesNo Does your child run at a comfortable speed in one direction and around objects? * Human Verification: What does 1+1=?