Pregnancy Information: (Describe anything out of the ordinary)
Breast feeding: (Describe the length and character of feeding effort)
Colic or milk intolerance
Formula: (Brand name or type)
Date of age you suspected delayed development
Does your child speak ?
Does your child lose spoken words? If so, describe speech regression:
Frequency and age of first ear infection(s)
Did your child lose social and/or motor skills? (yes/no) Describe:
Did you associate a decline in your child's functions after a vaccine? (MMR, DPT, Polio, etc.)
Does your child have asthma/allergies? Describe:
Major food cravings?
List all foods commonly consumed:
Describe bowel movements
Does your child have auditory defensive behavior?
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:
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;
Mouthing of toys or objects?
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?
Maternal Hx thyroid/auto immunity?