Initial Interview Form


Patient
First Name
Middle Name
Last Name
Preferred Name
Gender Male Female
Date of Birth (Format is DD/MM/YYYY example 01/01/1990)  /  /
Age
BMI Weight (kg)  Height (cm) 
Address
Mother
First Name
Last Name
Date of Birth (Format is DD/MM/YYYY)  /  /
Age
Occupation
Father
First Name
Last Name
Date of Birth (Format is DD/MM/YYYY)  /  /
Age
Occupation
Religious Preference
Phone Number
Who lives in the House?

Pregnancy Information: (Describe anything out of the ordinary)

Labor:

Induces Yes No
Forceps Yes No
C-section Yes No

Breast feeding: (Describe the length and character of feeding effort)

Colic or milk intolerance

Yes No

Formula: (Brand name or type)

Date of age you suspected delayed development

Does your child speak ?

Yes No

Does your child lose spoken words? If so, describe speech regression:

Yes
No

Frequency and age of first ear infection(s)

Did your child lose social and/or motor skills? (yes/no) Describe:

Yes
No

Did you associate a decline in your child's functions after a vaccine? (MMR, DPT, Polio, etc.)

Does your child have asthma/allergies? Describe:

Yes
No

Major food cravings?

List all foods commonly consumed:

Potty trained?

Yes No

Describe bowel movements

Does your child have auditory defensive behavior?

Yes No

What type of touch bothers your child? Describe

Describe the activities of daily living you must help your child with (dressing, feeding, bathing, etc.):

What aspects are most troubling to you?

Describe your child's sleep pattern from birth to now in simple terms:

Therapies

List all therapies your child has received:

List all current therapies:

School programs and grade level:

Medication and supplement

List all medications currently used: (Any medication allergies?)

List all medications that have failed to help and those that reacted badly with your child:

List all current nutritional supplements:

List any nutritional supplements that you think have helped your child:

What has benefited your child the most?

Is your child Right or Left Handed? (write one or both if confused)

List any accident or trauma;

PICA?

Yes No

Mouthing of toys or objects?

Yes No

Surgery (list all procedures and dates)

Other medical problems:











List all diagnostic tests performed on your Child: (Chromosomes, MRI, EEG, etc.)

What are your goals for your child's medical care? (in order of importance)

What else would you like us to know about your child or family?

Miscarriages?

Yes No Don't know

Maternal Hx thyroid/auto immunity?

Yes No Don't know

Diabetes

Yes No Don't know

Cerebral palsy

Yes No Don't know